post-op leaks in bariatric surgery - gandsas 02-07
TRANSCRIPT
Alex Gandsas, MD, FACSAlex Gandsas, MD, FACS
Head , Division of Bariatric and Minimally Invasive Surgery
Head , Division of Bariatric and Minimally Invasive Surgery
Post Operative LeaksPost Operative Leaks
Statistics
• 1990 -> 16,000 procedures
• 2003 -> 103,000 Procedures
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Post Operative Leaks
• 2005 -> 140,000 Procedures
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Post Operative Leaks
Complications:
• Leaks ……………………….. 2-4%• DVT ………………………… 2%• Pulmonary Embolism ……...
<1%• Small Bowel Obstruction …..
2%• Strictures ………………….... 15%• Stoma Ulcers ………………. 2-4%• Incisional Hernias …………...
20%
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Post Operative Leaks
Epidemiology:
Open: 1.6%
Laparoscopy 3- 4%
Revisions 35%
Marshall JS. Arch Surg. 2003. 138:520-524
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Post Operative Leaks
Leaks:Esophageal Perforation (4 %)
Gastro Jejunostomy (52%)
Remnant Stomach (8%)
Small bowel perforation (30%)
Jejuno jejunostomy (4%)
Schauer PR. 2002
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Post Operative Leaks
Etiology
Technical
Challenges• Anatomy (Liver
Size)• Tension• Blood Supply
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Post Operative Leaks
Anastomosis / Staple line leaks:
• Symptoms:• NOTHING (!) • Tachycardia on pod# 2-5
• Low urine output (third spacing)• Leukopenia • High amylase, high lactate• Hiccups• Brownish color of the drain output
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Post Operative Leaks
Anastomosis / Staple line leaks:
• Late Symptoms:• Left Pleural effusion• Left Subphrenic abscess• Fever• Tachycardia
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Post Operative Leaks
• Differential Diagnosis:
• Post op pain
• Atelectasis
• Dehydration
• Bleeding
• Hypoxia/Pulmonary
Embolism
Bowel injury
Mortality increases to 26% if the injury goes unnoticed for more than 24 hs.
Chandler et al. J Am Coll Surg. 2001; 192: 478-91
and increases to 46% if the patient is older than 59 years.
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Post Operative Leaks
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Post Operative Leaks
• Diagnosis:
• Tachycardia >120
• Physical exam
• Gastrografin Swallow
• CT-Scan
•Laparotomy / laparoscopy
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Post Operative Leaks
Gastrografin Swallow
• No need for x-rays if patient is asymptomatic (Singh. Obes Surg. 2003; 13:73-74)
• Low Sensitivity (Hamilton EC. Surg Endosc. 2004 mar;18(3):559)
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Post Operative Leaks
• Intraoperative Endoscopy:
- Allows direct visualization of the anastomosis
- Identified 34 correctable errors in 825 cases
- Principle: high Pressure air tight staple line is less likely to leak fluids under low pressure.
Champion JK. Surg Endo. 2002. 16:1663-1665
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Post Operative Leaks
Management:Management:
• Medical
• Surgical
Lavage
Gastrotomy tube
Nutrition
Drainage
Infection control
Support
Closure of defect if possible
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Post Operative Leaks
• Movie
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Post Operative Leaks
LEAKS
N= 1789
Incidence: 1.34%
Tachycardia: 83% *
Fever: 70% *
Left Side pain: 44%
Arteaga JR. Am Surg. 2002; 68:1061-65
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Post Operative Leaks
N=210 Leak
N=9
No Leak
N= 201
Tachycardia 90% 16%
Fever 25% 42%
Respiratory Distress 67% 10%
Low Urine Output 33% 7%
Positive Gastrografin 22% 0%
Hamilton EC. Surg Endosc. 2003; 17:679-
648
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Post Operative Leaks
Facts:
Tachycardia when associated with
Fever is one of the earliest sign of
anastomotic leak following GBP
Buckwalter JA. Surgery. 1988; 103:156-
60
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Post Operative Leaks
How Can I Avoid a post operative LEAK?
How Can I Avoid a post operative LEAK?
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Post Operative Leaks
Don’t Operate !Don’t Operate !
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Post Operative Leaks
• if you do:
• Avoid tension of Roux limb
• Assess blood supply
• Consider Intraop. Endoscopy
• Consider “Air test”
• Aggressive post op monitoring
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Post Operative Leaks
Also:
• Bovine pericardial strips
- decrease bleeding
- decrease leaks
Shikora SA. Obes Surg. 2003; 13:37-39.
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Post Operative Leaks
Liu CD. Obes Surg. 2003; 13:45-48.
Sapala. Obes Surg. 2004; 14:35-42
• useful in “high risk anastomosis
• may be cost effective
Fibrin Glue Sealant
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Post Operative Leaks
• When in doubt:
• Oversewing of staple line
• Gastrostomy tube
• Small bowel interposition
• Consider “bubble test”
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Post Operative Leaks
• Remember:
If in doubt: operate!
Can still have “leaks” from other
sources