LEAKS IN BARIATRIC SURGERY

Paolo GentileschiBariatric Surgery Unit

University of Rome Tor Vergata

LEAKS IN BARIATRIC SURGERY

+ 142%

LEAKS

Mortalità < 30 giorni (precoce) : 0,28% > 30 giorni (tardiva) : 0,35%

Pazienti SuperObesi:

Mortalità Precoce: 1,25% Mortalità Tardiva: 0,81%

Pazienti con età> 65 anni

Mortalità Precoce: 0,34% Mortalità Tardiva: 0,0%

Postoperative Adverse Events by Bariatric Procedure in Controlled Trials.

Maggard M A et al. Ann Intern Med 2005;142:547-559

Local and Systemic Factors that negatively influence suture integrity

Leaks 0-6 %

Sleeve GastrectomySleeve Gastrectomy Sleeve GastrectomySleeve Gastrectomy

LEAK RATE BY PROCEDURELAGB 0%LSG 0-7%

LRYGB 0-7%LBPD 0-6%

RCTs

Int’l Consensus Summits on Sleeve Gastrectomy

 Comparative Use of Different Techniques Comparative Use of Different Techniques for Leaks and Bleeding prevention during for Leaks and Bleeding prevention during

Laparoscopic Sleeve GastrectomyLaparoscopic Sleeve Gastrectomy

M.AnselminoM.Anselmino, N. Basso*, P. Gentileschi°, L. Angrisani§, , N. Basso*, P. Gentileschi°, L. Angrisani§, G. Casella°, D. Benavoli°, S. D’Ugo°, P. Cutolo§, G. Casella°, D. Benavoli°, S. D’Ugo°, P. Cutolo§, C. Moretto, R. Bellini, R.D. Berta, S. FranceschiC. Moretto, R. Bellini, R.D. Berta, S. Franceschi

Bariatric & Metabolic Surgery Unit, PisaBariatric & Metabolic Surgery Unit, Pisa*VII Dept. of Surgery, Rome La Sapienza*VII Dept. of Surgery, Rome La Sapienza

§Dept. Of General Surgery, S. G. Bosco Hospital, Naples§Dept. Of General Surgery, S. G. Bosco Hospital, Naples°Bariatric Surgery Unit, Rome Tor Vergata°Bariatric Surgery Unit, Rome Tor Vergata

Center City Investigator

A.O.U.P. Pisa Anselmino

S. Giovanni Bosco Naples Angrisani

Tor Vergata University Rome Gentileschi

La Sapienza University Rome Basso

All cases of primary SG in 4 Italian Bariatric Centers

Company 

Synovis SI Covidien Gore Baxter

Product Brand Name Peri-Strips Dry withVeritas

Duet TRS SEAMGUARDBioabsorbable

FLOSEALTISSEEL

Material BovinePericardium

Synthetic polyester(Biosyn material)

Glycolide andTrimethyleneCarbonateCopolymer

Thrombine Haemostatic

matrix+

Fibrin Glue

Host TissueResponse

Remodels Reabsorbs Reabsorbs -

Tissue thickness Avg = 0.35 mm0.20 – 0.60 mm

Avg = 0.07 mm0.04 – 0.10 mm

0.25 mm -

Tensile strength(Peak load)

4.0 kg TBD 1.2 kg -

Storage Controlled room temp Ambient room temp Ambient room temp

 Preparation

One piece; requires gelapplication

Pre-loaded on stapler loads; attached with

Biosyn sutures

Two pieces; sleeves fit on stapler

arms

COMPETITIVE LANDSCAPE

Reinforcement TypeReinforcement TypeReinforcement TypeReinforcement Type

ResultsResultsResultsResults

CONCLUSIONS

No evidence at this time for minor incidence of leaks with either materials or oversewing

- Sufficient evidence of less episodes of bleeding with reinforcement with either strips

LEAKS

Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy

SERIES (Policlinico Tor Vergata Roma)March 2013

382 LSG (primary)6 LEAKS (1.5%)

Laparoscopic Sleeve Gastrectomy

5 healed with :2 with laparoscopic drainage and TPN

3 with endoscopic clipping and stenting

1 Mortality :Pulmonary failure and sepsis

IL BY-PASS GASTRICO

Complicanze dopo By Pass gastrico Complicanze dopo By Pass gastrico sec. Rouxsec. Roux

Precoci (entro 30 giorni)Precoci (entro 30 giorni) TardiveTardive

Fistola 2-7% Fistola 2-7% Embolia polmonare 0,2-1%Embolia polmonare 0,2-1% Infezione ferita 8% Infezione ferita 8% Emorragia 0,8-4,4% Emorragia 0,8-4,4% Insufficienza respiratoria 1-Insufficienza respiratoria 1-

4% 4%

Ernia ferita chirurgica 12-15% Ernia ferita chirurgica 12-15% Occlusione intestinale 1-3%Occlusione intestinale 1-3% Stenosi delle anastomosi 3-7% Stenosi delle anastomosi 3-7% Anemia da carenza di Ferro Anemia da carenza di Ferro

e/o vitamimina B12 e/o acido e/o vitamimina B12 e/o acido folico 15-33%* folico 15-33%*

Osteoporosi da carenza di Osteoporosi da carenza di calcio 8-10% * calcio 8-10% *

Ulcera marginale 1-16%Ulcera marginale 1-16%

LEAKS DOPO BY-PASS GASTRICO

Serie (Policlinico Tor Vergata)Marzo 2013

464 pz1 leak anastomosi gastro-digiunale (0.2%)

Re-intervento, drenaggio, NPT1 leak anastomosi entero-entero (0.2%)

Re-intervento, riconfezionamento

STENTINGSTENTING STENTINGSTENTING

STENTINGSTENTING STENTINGSTENTING

La II causa più comune di morte dopo La II causa più comune di morte dopo RYGBRYGB

Leak Anastomosi G-J :Leak Anastomosi G-J : Incidenza 2-5%Incidenza 2-5% - LRYGB: 5,2%- LRYGB: 5,2% - ORYGB:2,6%- ORYGB:2,6% Mortalità 1,5%Mortalità 1,5%Tempo medio per la diagnosi: 2 giorniTempo medio per la diagnosi: 2 giorni

Leak anastomosi J-JLeak anastomosi J-JMortalità: 40%Mortalità: 40%Tempo Medio per la diagnosi: 4 giorniTempo Medio per la diagnosi: 4 giorni

Diagnosi Diagnosi Leak anastomoticiLeak anastomotici

Segni e/o Sintomi:Segni e/o Sintomi: Dolori addominale Tachicardia Iperpiressia Aumentati segni di flogosi: VES,

PCR, ProCalcitonina Leucocitosi Neutrofila Distress respiratorio Studio Radiologico:Studio Radiologico: Rx digerente con Gastrografin Tc con mdc per os

Complicanze Precoci: Leak AnastomoticiComplicanze Precoci: Leak Anastomotici

Leak AnastomoticiLeak AnastomoticiTrattamentoTrattamento

Pz StabilePz Stabile

No segni di shock settico,No segni di ampio Leak

Trattamento ConservativoTrattamento Conservativo DigiunoDigiuno

NPTNPT Antibtioticoterapia e.v.Antibtioticoterapia e.v.

SNGSNG STENTSTENT

Presenza di Raccolta AddominalePresenza di Raccolta Addominale

Drenaggio percutaneo TC-guidatoDrenaggio percutaneo TC-guidato

Pz InstabilePz Instabile

Segni shock SetticoSegni radiologici di ampio Leack

ReinterventoReintervento

Relaparoscopia LaparotomiaRelaparoscopia Laparotomia

Lavaggio raccolte intraddominaliLavaggio raccolte intraddominaliPosizionamento di Drenaggi AspirativiPosizionamento di Drenaggi Aspirativi

Sutura diretta LeakSutura diretta Leak

Treated 19 patients with removable covered stents

-acute leaks (n=11)-chronic fistulas (n=2)

-strictures (n=6)

Leaks were identified endoscopically, marked radiographically,

and stents deployed under fluoroscopy.

Oral feeding could be started in 79% of the patients after

stenting. At a follow up of 3.6 months

successful healing was achieved in :

• 91% of acute leaks• 100% of gastrocutaneous

fistulas • 81% of strictures

Mean healing time of 30 days

Treatment of Leaks and Other Bariatric ComplicationsTreatment of Leaks and Other Bariatric Complicationswith Endoluminal Stentswith Endoluminal Stents

Treatment of acute fistolaInfected fluid collection

Percutaneus or laparoscopic dranaige

Acute fistola

Applications of stents were extended to treat esophageal

and gastrointestinal leaks

Healed anastomotic leak after stent removal

LEAKS

PREVENTIONAPPROPRIATE SURGICAL TECHNIQUE

STAPLE LINE REINFORCEMENT (?)suture

buttress materialsealants

MET BLUE TESTINGNG TUBE (?)

DIAGNOSISENDOSCOPY WITH FLUOROSCOPY

CT SCAN

TREATMENTCONSERVATIVE

DrainageTPN

STENTINGEndoscopic clipping or sealants (?)