A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Bariatric Times • September 2011
Ask the Experts, Total Bariatric Care, Continued
ASK THE EXPERTS: Dilemmas in Bariatric Surgery
Continued from page 24
Other operative options include the injection of fibrin glue into the defect, construction of a Roux-en-Y loop if the defect is large, and finally total gastrectomy. In patients with long- standing leaks, closure of the defect may not be possible due to
inflammatory changes; therefore, lavage and wide drainage may be the best option.
Although reoperation has its place in the treatment armamentarium for gastric leak following SG, current trends favor reoperation as the exception after conservative therapies have been exhausted.
CONCLUSION
The management of a gastric leak following SG should be based on a prompt control of the septic state and providing adequate nutrition. Control of the fistula can be achieved by the use of covered stent with or without the combination of additional surgery.
FOLLOW UP FROM THE TREATING SURGEON ON THE CASE PRESENTED
Successful treatment was achieved and the fistula closed seven weeks after percutaneous drainage of the collection and placing the patient NPO.
REFERENCES 1. Tucker ON, Szomstein S, Rosenthal RJ. Indications for sleeve gastrectomy as a primary procedure for weight loss in the morbidly obese. J Gastrointest Surg. 2008;12(4):662–667.
2. Roa PE, Kaidar-Person O, Pinto D, et al. Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcome. Obes Surg. 2006;16(10):1323–1326
3. Gandsas A, Li C, Tan M, et al. Initial outcomes following laparoscopic sleeve gastrectomy in 292 patients as a single-stage procedure for morbid obesity. Bariatric Times. 2010;7(2):11–13.
4. Casella G, Soricelli E, Rizzello M, et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg. 2009;19(7):821–826.
5. Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. Sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis. 2007;3(6):573–576.
6. Nguyen NT, Nguyen XM, Dholakia C. The use of endoscopic stent in management of leaks after sleeve gastrectomy. Obes Surg. 2010;20(9):1289–1292.
7. Eubanks S, Edwards CA, Fearing NM. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008;206(5):935–938; discussion 938–939.
8. Csendes A, Braghetto I, León P, Burgos AM. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg. 2010;14(9):1343–1348.
9. Salminen P, Gullichsen R, Laine S. Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks. Surg Endosc. 2009;23(7):1526–1530.
10. de Aretxabala X, Leon J, Wiedmaier G, et.al. Gastric leak after sleeve gastrectomy: analysis of its management. Obes Surg. 2011;21(8):1232–1237.
11. Tan JT, Kariyawasam S, Wijeratne T, Chandraratna HS. Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg. 2010;20(4):403–409.
12. Court I, Wilson A, Benotti P, et al. T- tube gastrostomy as a novel approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case report and review of the literature. Obes Surg. 2010;20(4):519–522.
13. Jurowich C, Thalheimer A, Seyfried, et al. Gastric leakage after sleeve gastrectomy-clinical presentation and therapeutic options. Langenbecks Arch Surg. 2011 May 10. [Epub ahead of print]
14. Lacy A, Ibarzabal A, Pando E, et al. Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20(5):351–356.
ADDRESS FOR CORRESPONDENCE Alex Gandsas, MD, MBA, FACS, Professor and Chair, Department of Surgery, UMDNJ-SOM, 42 East Laurel Road, Suite 2600, Stratford, NJ 08084; Phone: (856) 566-7049; Fax: (856) 566- 6438
SUBMIT YOUR OWN DILEMMA To submit a dilemma, e-mail Angela Hayes at ahayes@matrixmedcom.com. Include "Ask the Experts" in the subject line of your e-mail. Include a case description (250 words or less) along with 1 to 5 questions relevant to the case. All chosen dilemmas will be published anonymously. All dilemmas are reviewed by the editors and are selected based upon interest, timeliness, and pertinence, as determined by the editors. There is no guarantee a submitted dilemma will be published or answered. Published dilemmas are edited and may be shortened.
TOTAL BARIATRIC CARE
Continued from page 26
So, if there are 2,500 bariatric surgeons in the United States (this number is higher than most estimates), we would each potentially need to have 800 visits each year (16 visits per week) in order to keep up with our patients' during the last five years. Now, increase the number of people needing care to reflect a 10-year period of high-volume bariatric surgery in the United States and you will find our 2,500 bariatric surgeons need to provide three million patient encounters per year (15 times the number of surgeries), or 24 visits per week just to keep up
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by ERIC J. DEMARIA, MD
impossible burden to place on this specialty and we must seek new answers to this problem. In my first column of "Total Bariatric Care," I asked, "Aftercare—are we providing value to our patients?" and answered it with a resounding "no." Although some viewed this as a criticism of colleagues and the specialty as a whole, I do not agree. I have found that most of our colleagues are genuinely concerned about their patients, butI believe we are fighting a losing battle in this numbers game. I think our only failure is that we have not been able to figure out a better system of care to make certain our patients' needs are met long term.
The number of potential follow-up visits could easily approach five million per year (2,000 routine encounters per surgeon per year) or more if each patient returned as our guidelines recommend for their annual follow-up care.
with the aftercare needs of patients. And this model does not reflect the estimate of 250,000 procedures per year, which some believe to be more accurate. Bariatric surgery, although it has grown in recent years, has been around for decades, so these numbers are very conservative in estimating the amount of care bariatric surgeons really would need to provide to patients long term if they followed our guidelines for annual follow-up care. The number of potential follow-up visits could easily approach five million per year (2,000 routine encounters per surgeon per year) or more if each patient returned as our guidelines recommend for their annual follow- up care. This number will continue to grow and outpace our available resources as bariatric surgeons. Is it any wonder that surgeons might be considered ambivalent about patients not coming back for follow-up care? Could we realistically fit this many patients into our clinic schedules? We probably would not be able to be surgeons with this exponentially increasing burden of providing long- term care if patients actually came back as they are supposed to do. I conclude that the bariatric surgeon workforce cannot support the follow-up care of all bariatric surgery patients long term. It is an
In Part 2 of this installment, I will delve into what I believe to be a relatively simple and rapidly attainable strategy to improve our flawed long-term system of care. I believe a reasonable answer lies in equipping our primary care providers with the education and skills they need to provide high- quality care to our patients long term, and in publically identifying providers who have acquired this knowledge and skill so that the public can seek out their care. It would be my hope that we surgeons might—even briefly—take our focus off the surgical procedures themselves long enough to debate and ultimately introduce some solutions to the issue of providing quality long-term care to our patients.
I believe it is past time to solve this problem. Our patients' long- term success and safety depend on it.
ADDRESS FOR CORRESPONDENCE Eric J. DeMaria, MD, New Hope Wellness Center, 9910 Strickland Rd, Raleigh, NC 27615; E-mail: ejdemaria@gmail.com