Recent Advances in Management of Leak After Bariatric Surgery

Ahmed Mohamed Elsaid Mohamed Agamy;

Abstract


Obesity has become a pandemic, with billions of people across the globe now overweight or obese. As such, the management of this crisis is one of the greatest challenges facing the healthcare profession across the world.
Bariatric surgical procedures are categorized into 2 main types; restrictive and malabsorptive. Some operations combine both Restriction and malabsorption. The operations that are most frequently performed are the Roux-en-Y gastric bypass, mini-gastric bypass, and duodenal switch. Laparoscopic sleeve gastrectomy is an increasingly used bariatric surgical procedure with sporadically reported complication rates. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is an operation, was created recently with many advantages.
One of the most feared complications of bariatric surgery is the anastomotic leak. Leak causes can be divided into two categories: mechanical– tissular causes and ischemic causes. In both situations, intraluminal pressure exceeds tissular and suture line resistance, thus causing the fistula. Leaks are thought to be the result of other etiologies including stapler misfire, wrong staple size for the tissue, tissue trauma, or ischemia due to either tension on the anastomosis or a hematoma.
The clinical presentation of gastric leak ranges from the patient being completely asymptomatic, to the presentation of peritonitis, septic shock, multi-organ failure, and death. Abdominal pain, fever, tachycardia, tachypnea, and increased laboratory signs of infection are signs of leakage. It was observed that tachycardia is an initial sign of early leak.
There are many tools for leak diagnosis which include: methylene blue test, gastrointestinal transit test and radiological investigations as ultrasonography and computerized axial tomography.
Radiology plays a critical role in diagnosis of leak through Upper GI contrast study and CT. Also, Radiology has therapeutic roles in management of leak through pigtail catheter drainage. CT-guided percutaneous catheter drainage is an effective and safe procedure for the management of infected abdominal collections due to gastric leak.
Endoscopic management of anastomotic leaks through the temporary placement of self-expanding metal stents (SEMS) has become more popular in recent years due to improvements in endoscopic techniques and due to being less invasive than primary surgical repair. Endoscopic procedures could be conducted under fluoroscopic guidance with patients under general anesthesia. Two types of SEMS were used: partially covered nitinol Ultraflex stents and partially covered Cremer nitinol stents.
Any abdominal collection caused by leak should be drained either by laparoscopic or percutaneous means in combination with nothing per oral and nutritional support with either total parenteral nutrition or jejunostomy feeding to ensure resolving the leak complication.
In case of an intra-abdominal drain having been inserted primarily, no further measures might be necessary. Re-laparoscopy, lavage, and insertion of an intra-abdominal drain are necessary in case of removal or absence of a drain. Reoperation and primary repair of the leak are performed early after surgery (i.e., postoperative day 2), when the defect can be easily identified and the local tissues are not severely inflamed. Re-suture or resection of the staple line may be a possible solution to the problem only in case of distal leakage. Re-suture of proximal leakages is not helpful.
The recent updates of leak management include: endoscopic application of biological glue and endoluminal vacuum therapy for gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass. Biological glue technique is available when the fistula persists for more than 4 weeks or the size of collection does not clearly decrease. On the other hand, Endoluminal vacuum therapy is a new method for both the prevention and management of anastomotic leaks based on the principles of negative pressure wound therapy.


Other data

Title Recent Advances in Management of Leak After Bariatric Surgery
Other Titles التطورات الحديثة في علاج التسريب بعد جراحات السمنة
Authors Ahmed Mohamed Elsaid Mohamed Agamy
Issue Date 2016

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