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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 (?)