Diagnosis and Contemporary Management of Anastomotic Leaks after Gastric Bypass for Obesity

González, Ricardo Rodríguez; Sarr, Michael G.; Smith, C. Daniel; Baghai, Mercedeh; Kendrick, Michael L.; Szomstein, Samuel; Rosenthal, Raúl J.; Murr, Michel M.

doi:10.1016/j.jamcollsurg.2006.09.023

Cited by 239 publications

(153 citation statements)

References 17 publications

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“…The third accepted technique is the hand-sewn gastrojejunostomy originally promoted by Higa et al [24]. Although hand-sewn anastomoses may take longer to perform, they result in a lower hospital cost, less anastomotic bleeding, fewer stricture complications, and a lower incidence of wound infection [24][25][26]. In addition, the use of absorbable suture to create the gastrojejunostomy reduces the risk of gastrogastric fistula and marginal ulceration [27].…”

Section: Discussionmentioning

confidence: 99%

Robot-assisted gastrojejunal anastomosis does not improve the results of the laparoscopic Roux-en-Y gastric bypass

et al. 2010

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Background Traditional laparoscopic surgery presents some difficulties for morbidly obese patients due to limited motion of instruments related to a thick abdominal wall, intraabdominal fat, and a large hepatic left lobe, with consequent loss of dexterity and greater musculoskeletal discomfort. Robotic technique could potentially overcome these limitations. This study aimed to evaluate robot-assisted laparoscopic Roux-en-Y gastric bypass in morbidly obese patients and to compare the results of robotic assistance with those of traditional laparoscopic technique. Methods Between September 2006 and June 2009, 110 morbidly obese patients underwent laparoscopic Roux-en-Y gastric bypass with robot-assisted hand-sewn gastrojejunal anastomosis using the da Vinci Surgical System. The data for these patients was compared with the data for 423 consecutive patients treated in a standard laparoscopic manner during the same period. Results The patients had a mean preoperative age of 42.6 years, a mean weight of 127.5 kg, and a mean body mass index (BMI) of 46.7 kg/m 2 . The total mean operative time was 247.5 min. The robotic setup time was 10.1 min, and the robotic operative time was 54.5 min. The conversion rate was nil. The intraoperative complication rate was 4.5%. The early and late major postoperative complication rates were 3.6 and 6.4% respectively. The cost per patient was 5777.76 €. For the standard laparoscopy, the operative time was significantly shorter (187 min; p < 0.001), and the costs per patient were significantly lower (4658.28 €; p < 0.001), whereas no differences were found in terms of the intra-or postoperative complication rates, revisional surgery, or hospital length of stay. Conclusions Although safe and intuitive, the robotic approach was burdened by a longer operative time and higher equipment costs. Moreover, it did not seem to provide a real advantage over standard laparoscopy in terms of hospital length of stay and complications rates. Keywords Bariatric surgery Gastrojejunal anastomosis Morbid obesity Robot-assisted gastric bypass Robotic surgery Roux-en-Y gastric bypass To date, bariatric surgery is the only long-term effective therapy available for the morbidly obese population [1][2][3]. Over recent decades, laparoscopic surgical techniques have become the gold standard in bariatric surgery due to advantages such as less postoperative pain, shorter hospital stay, faster postoperative recovery, and minimal scarring [4][5][6]. Moreover, for the obese patient, the mini-invasive approach has demonstrated its ability to reduce postoperative mortality [7,8]. However, the inherent limitations of traditional laparoscopic surgery may cause some technical difficulties due to the limited freedom of motion for the instruments related to the thick abdominal wall and hepatomegaly, with consequent loss of dexterity and greater musculoskeletal discomfort for the surgeon [9].

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Section: Discussionmentioning

confidence: 99%

Robot-assisted gastrojejunal anastomosis does not improve the results of the laparoscopic Roux-en-Y gastric bypass

et al. 2010

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“…A large case series of 63 patients with leaks after RYGBP reports that most were not detected by CT imaging and that most required surgery (63%), with morbidity of 53% and mortality of 10% 22 . In case of small fistulas, the rate of escape of contrast will be small, so that leaks may be overlooked by radiography.…”

Section: Discussionmentioning

confidence: 99%

Biodistribution of technetium-99m pertechnetate after Roux-en-Y gastric bypass (Capella technique) in rats

et al. 2010

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Biodistribution of technetium-99m pertechnetate after Roux-en-Y gastric bypass (Capella technique) in ratsABSTRACT Purpose: The biodistribution of sodium pertechnetate, the most used radiopharmaceutical in nuclear medicine, has not been studied in details after bariatric surgery. The objective was to investigate the effect of Roux-en-Y gastric bypass (RYGB) on biodistribution of sodium pertechnetate (Na 99m Tc -) in organs and tissues of rats. Methods: Twelve rats were randomly divided into two groups of 6 animals each. The RYGB group rats were submitted to the Roux-en-Y gastric bypass and the control group rats were not operated. After 15 days, all rats were injected with 0.1mL of Na 99m Tc -via orbital plexus with average radioactivity of 0.66 MBq. After 30 minutes, liver, stomach, thyroid, heart, lung, kidney and femur samples were harvested, weighed and percentage of radioactivity per gram (%ATI/g) of each organ was determined by gama counter Wizard Perkin-Elmer. We applied the Student t test for statistical analysis, considering p<0.05 as significant. Results: Significant reduction in mean %ATI/g was observed in the liver, stomach and femur in the RYGB group animals, compared with the control group rats (p<0.05). In other organs no significant difference in %ATI/g was observed between the two groups. Conclusion: This work contributes to the knowledge that the bariatric surgery RYGB modifies the pattern of biodistribution of Na 99m Tc -.

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“…< 30 d and late complications, seen after the first 30 d. Total post-surgical complications or adverse effects following a gastric bypass can be as high as 16% (11) (see Table 2 for surgical complications that may result in nutritional consequences). The complications that are likely to be present early are anastomotic leaks, haemorrhages, fistulas and perforations, whereas anastomotic strictures, bowel obstructions and band erosions are more likely to occur after the first 30 d (2,(11)(12)(13)(14) . Anastomotic leaks are the most common gastrointestinal complication occurring in 2-5% of laparoscopic gastric bypass cases (11)(12)(13)(14) .…”

Section: Complications Following Bariatric Surgerymentioning

confidence: 99%

“…The complications that are likely to be present early are anastomotic leaks, haemorrhages, fistulas and perforations, whereas anastomotic strictures, bowel obstructions and band erosions are more likely to occur after the first 30 d (2,(11)(12)(13)(14) . Anastomotic leaks are the most common gastrointestinal complication occurring in 2-5% of laparoscopic gastric bypass cases (11)(12)(13)(14) . Kumpf and co-workers (15) in their survey of nutritional practices with complications postbariatric surgery reported anastomotic leaks as the most common indication for nutrition support.…”

Section: Complications Following Bariatric Surgerymentioning

confidence: 99%

“…In addition, those with BMI >50 kg/m 2 have a significantly higher overall rate of major complications (16) . These surgical complications may cause nutritional problems as oral intake is often restricted or prohibited until the complication has resolved (14) . This imposes the need for enteral or parenteral nutrition (PN) and this can be for a considerable period of time.…”

Section: Complications Following Bariatric Surgerymentioning

confidence: 99%

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Provision of nutritional support to those experiencing complications following bariatric surgery

Segaran

2010

Proc. Nutr. Soc.

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This review details the practicalities of providing nutrition support to obese patients who experience complications following bariatric surgery and highlights some of the nutritional challenges encountered by this group of patients. Bariatric surgery to treat morbid obesity has significantly increased internationally over the past decade with hospital admissions rising annually. The gastric bypass is currently the most commonly performed procedure. The complication rate can be up to 16%, with a considerable proportion having nutritional implications. The treatment can involve avoidance of oral diet and nutrition support, i.e. enteral or parenteral nutrition. Opposition to nutrition support can be encountered. It is useful to clarify the aims of nutrition support, these being: the avoidance of overfeeding and its consequences, preservation of lean body mass and promotion of healing. Evidence suggests that hypoenergic nutrition is not harmful and may actually be beneficial. There is a lack of consensus regarding the optimum method to predict the nutritional requirements in the obese acutely unwell patient. The literature suggests that the predicted equations are fairly accurate compared to measured energy expenditure in free living obese patients before and after bariatric surgery. However, these findings cannot be directly applied to those obese patients experiencing complications of bariatric surgery, who will be acutely unwell exhibiting inflammatory response. It is therefore necessary to refer to the literature on energy expenditure in hospitalized obese patients, to help guide practice. More research examining the energy and protein requirements of obese patients needing nutrition support following bariatric surgery is urgently required.

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Diagnosis and Contemporary Management of Anastomotic Leaks after Gastric Bypass for Obesity

Cited by 239 publications

References 17 publications

Robot-assisted gastrojejunal anastomosis does not improve the results of the laparoscopic Roux-en-Y gastric bypass

Robot-assisted gastrojejunal anastomosis does not improve the results of the laparoscopic Roux-en-Y gastric bypass

Biodistribution of technetium-99m pertechnetate after Roux-en-Y gastric bypass (Capella technique) in rats

Provision of nutritional support to those experiencing complications following bariatric surgery

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