A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/69664
CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY Part 2: PERIOPERATIVE PREVENTION: Complications Management X-ray image of a patient who developed a leak after undergoing sleeve gastrectomy. chronic: 1. The inherent poor vascular supply at the angle of His 2. The absence of the remnant stomach that could "block" the leak I 3. The "physiologic" obstruction of the pylorus 4. The narrowing at the level of incisura angularis 5. The deviation on the antrum's axis 6. The possible curling/twisting of the sleeve 7. The fact that SG has the longest staple line of all bariatric surgeries 8. The fact that being so "high," the sleeve is under negative pressure of the thorax 9. The fact that the SG is a high-pressure "closed" system instead of a "draining" system like the gastric bypass. X-ray image of a patient who developed a stricture after undergoing sleeve gastrectomy. n my opinion, the following group of conditions may contribute to higher rate of SG leaks that do not respond to conservative or traditional surgical approach (e.g., suturing) and become LEAKS According to the observation period, leaks can be acute, early, late, and chronic If a leak lasts >12 weeks, it is considered chronic EXPERT COMMENTARY Manoel Galvao Neto, MD Gastro Obeso Center, São Paulo, Brazil The SG consensus experts agreed that stenting is a valid treatment option for acute proximal leaks and has limited utility for chronic leaks. In our experience, endoscopic treatment with stents in early leaks, and pneumatic dilation in chronic leaks, play a major role after initial surgical or percutaneous sepsis control. Also in our experience, surgical repair is usually appropriate if endoscopic approach fails and can be done by means of seromyotomy, converting the sleeve to a Roux-en-Y gastric bypass, bypassing the leak with a bowel limb and even with a total gastrectomy. W e now better understand the technical aspects that can cause strictures after a laparoscopic sleeve gastrectomy. The SG consensus expert panel agreed with other published data that the incisura angularis is the site with the greatest potential for strictures, but we should not forget that strictures can occur elsewhere in the sleeve. The consensus panel also agreed that maintaining symmetric lateral traction, while stapling, will reduce the potential for strictures. The symptoms of stricture usually start in the first six weeks after surgery, so aggressive but nonsurgical management should be implemented. Management includes close observation followed by endoscopic dilation up to six weeks. The option of using stents to keep the lumen open was not presented to the panel but is occasionally necessary in our experience. STRICTURES Early strictures are symptomatic in first 6 weeks after surgery The smaller the bougie size, the tighter the sleeve, the greater stricture rate EXPERT COMMENTARY Natan Zundel, MD, FACS Florida International University College of Medicine, Miami, Florida The consensus panel agreed largely (88%) that laparoscopic Roux-en-Y gastric bypass (RYGB) is the treatment of choice after failed interventions for strictures. On the other hand, even though seromyotomy was mentioned as an option, it did not reach consensus (69%) as a valid option for failed endoscopic treatment. We need to learn more about this complication, especially because it often appears at the same time as leaks and we cannot treat one without treating the other. [JUNE 2012, SUPPLEMENT B] Bariatric Times B5