Alex Gandsas, MD, FACS

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Post Operative Leaks
Alex Gandsas, MD, FACS
Head , Division of Bariatric and Minimally
Invasive Surgery
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Post Operative Leaks
Statistics

• 1990 -gt 16,000 procedures

• 2003 -gt 103,000 Procedures

• 2005 -gt 140,000 Procedures

Gandsas
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Post Operative Leaks
Complications

• Leaks .. 2-4
• DVT 2
• Pulmonary Embolism ... lt1
• 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. 138520-524
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Post Operative Leaks
Leaks
Esophageal Perforation (4 )
Small bowel perforation (30)
Gastro Jejunostomy (52)
Remnant Stomach (8)
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

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Post Operative Leaks
Bowel injury
Mortality increases to 26 if the injury goes
unnoticed for more than 24 hs.
and increases to 46 if the patient is older
than 59 years.
Chandler et al. J Am Coll Surg. 2001 192 478-91
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Post Operative Leaks

• Diagnosis
• Tachycardia gt120
• Physical exam
• Gastrografin Swallow
• CT-Scan
• Laparotomy / laparoscopy

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Post Operative Leaks
Gastrografin Swallow

• Low Sensitivity
• (Hamilton EC. Surg Endosc. 2004 mar18(3)559)

• No need for x-rays if patient is asymptomatic
• (Singh. Obes Surg. 2003 1373-74)

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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. 161663-1665
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Post Operative Leaks
Management

• Medical
• Surgical

Lavage
Closure of defect if possible
Gastrotomy tube
Drainage
Infection control
Nutrition
Support
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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 681061-65
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Post Operative Leaks
Hamilton EC. Surg Endosc. 2003 17679-648
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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 103156-60
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Post Operative Leaks
How Can I Avoid a post operative LEAK?
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Post Operative Leaks
Dont 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 1337-39.
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Post Operative Leaks
Fibrin Glue Sealant

• useful in high risk anastomosis
• may be cost effective

Liu CD. Obes Surg. 2003 1345-48. Sapala. Obes
Surg. 2004 1435-42
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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

Gandsas