Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1002_Библиотеки_им_академика_М_И_Перельмана
.pdf
442
Fig. 48.1 Anatomical
conguration of a
traditional biliopancreatic
diversion with duodenal
switch (BPD-DS)
A. Shuchleib et al.
reported a leak rate of 0.6% [4]. In an earlier and a signicantly smaller study, that
same group reported a leak rate of 3.2% on primary BPD-DS [5]. In a series of 345
patients, Rabkin reported a 3.2% leak rate, of which 2% came from the staple line
and 1.2% from the duodenoileostomy (DI) [6].
As it would be expected, experience reduces the complication rates signicantly;
Biertho initially reported a 3% leak rate on a 1000 patient series, 1.5% coming from
the staple line and the rest from the DI.Three years later that same group reported
a 0.9% leak rate, 0.7% from the DI and 0.2% from the sleeve staple line [7, 8].
When performing revisional surgery, particularly while converting a gastric
bypass to a BPD-DS or SADI, the risk of complications is signicantly higher;
anecdotally the incidence of leaks after that procedure is around 20%; for that reason some experts recommend against doing this procedure altogether. While converting a sleeve to a single anastomosis or a traditional DS, short-term complication
rates should be similar to the ones with a primary procedure since the area where the
new anastomosis is taking place has not been manipulated.
48 Surgical Management ofLeaks
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 48.2 Anatomical
conguration of a single
anastomosis duodenal
switch (SADI)
443
When a SADI is performed, there are three potential sites from which a leak may
arise, and identication of it will be important. It could come from the sleeve staple
line, the duodenoileostomy (DI), or the duodenal stump; when a BPD-DS is done,
there’s also a potential leak site at the jejunoileostomy (JI).
As a general rule, leaks can be classied as acute (less than 7 days), early
(1–6weeks), late (7–12weeks), or chronic (>12weeks) [9].
The same way as it happens with other bariatric procedures, the presence of a
leak might not be apparent with the abdominal exam alone. Leaks should be suspected in patients with sustained tachycardia, hypotension, hypoxemia, or fever.
Imaging will be required in order to identify the leak site. CT scans with PO and IV
contrast can be used as well as a UGI series.
If the leak is coming from the duodenal stump inammation, air or a collection
could be appreciated in the scan; however, due to its location, contrast extravasation
won’t be observed, and sometimes a nuclear scan is required for a denitive
diagnosis.
Surgical management is usually reserved for very early leak, unstable patients
and patients who fail to improve with less invasive techniques (conservative
444
management, endoscopic techniques, interventional radiology procedures, or a
combination of them) and, lastly, for denite management when a surgical revision
is required.
In this chapter we’ll primarily describe the surgical treatment since the other
interventions are reviewed in different chapters from this book.
A. Shuchleib et al.
48.2 Early Surgical Management
Regarding the surgical management, there aren’t any absolute rules since management will be dictated depending on the patient’s condition, the amount of inammation around the tissues, and location and size of the leak and if a distal obstruction
is present. As a general rule, no leak/stula will be able to heal as long as there is a
downstream obstruction. For this reason, it is important to ensure that there isn’t an
area of stenosis, kinks, intraluminal hematoma, or any adhesions causing an obstruction distally while trying to correct a leak.
Regardless of the location of the leak, when it presents in the rst 1–2days, it
usually happens due to a technical issue or a stapler malfunction. In those situations,
particularly on the rst day if there isn’t a lot of inammation, the leak could potentially be corrected surgically. Depending on the location, it could be xed with
stitches at the anastomosis or at a staple line. In these cases, the abdomen should be
washed out, and drains should be left in place. In our opinion, if the area of the leak
is accessible to do a leak test, it should be done after the correction.
Other than the previously described scenario in which the leak presents very
early, most of the times correction at the time of the rst procedure won’t be possible since tissues will be signicantly inamed, and even if the tissues are closed at
that time, the leak will reappear, and the defect might grow since there may be more
tissue ischemia.
In those scenarios, the main purpose of the procedure is to control the source of
the infection and create a controlled stula with drains, so the overall state of the
patient improves.
48.3 Leak fromtheSleeve
Fortunately, leak rates from the sleeve of the duodenal switch appear to be lower
than in a primary sleeve. While comparing the incidence between leaks in sleeves,
despite not being a direct correlation, leak rates after a primary sleeve have been
reported to be between 0.75 and 3% which is signicantly higher than what is
observed in the BPD-DS or SADI [10]. This is expected since the sleeve in a duodenal switch is calibrated with a larger bougie, which has been shown to decrease
the leak rate [11].
48 Surgical Management ofLeaks
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
445
Leakage from the sleeve either as a primary procedure or as part of the duodenal
switch most commonly presents on the upper third of the stomach, and in the majority of cases, if there isn’t a technical issue or a stapler malfunction, the leak is
related to narrowing of the sleeve at the level of the incisura. This increases the back
pressure and creates a leak on the weakest point at the angle of His [12].
As was mentioned previously in this chapter, if the patient is unstable, the rst step
would be to do a surgical intervention. This could be done either open or laparoscopically depending on the expertise of the surgeon and the condition of the patient.
Additionally, to the washout and drainage of the abdomen, if the leak site is found and
is big enough, a T-tube drain can be inserted to control the leak better [13] (Fig.48.3).
However, if the opening is not obvious, extensive dissection looking for it should
not be done since this could generate more trauma to the already inamed tissues
and could worsen the situation [13].
If the patient is stable before attempting a denitive management with surgery,
less invasive radiological and endoscopic procedures should be attempted. When
there isn’t a distal obstruction, the patient is stable, and the leak is contained,
Fig. 48.3 Placement of a
T-tube on the leak site
from the sleeve
gastrectomy
446
A. Shuchleib et al.
conservative management can be attempted with antibiotics, NPO status, and either
distal feeding with a nasojejunal tube or TPN.
From the radiological standpoint, the main intervention that is performed is a
drainage if there is either an abscess or the leak is not contained and it drains freely
into the abdomen.
Multiple endoscopic techniques exist to try to resolve the problem. Since they
will be explained with further detail in a different chapter, they will just be briey
mentioned. If there is a narrow area at the incisura, it’s important to dilate this area
rst before doing any additional therapies; otherwise the leak site is unlikely to heal.
Some of the other options that can be used are self-expanding stents, endoluminal
vacuum therapy, endoscopic internal drainage, septotomy, or some other techniques
less used like brin glue or over the scope clips. The efcacy of the different techniques varies signicantly [14].
When those therapies fail, then a denitive surgical management should be done,
ideally when the patient is stable and with a better nutritional status. Traditionally,
three surgical alternatives exist for patients that have a sleeve leak. Those procedures are stulojejunostomy, conversion to a traditional Roux-en-Y gastric bypass
if the level of the leak is not too high, and, lastly, an esophagojejunostomy with a
RY conguration when the leak is high.
Converting this procedure into a RY is probably the best option (Fig.48.4), if all
the less invasive procedures fail, the anastomosis to be created could be either a
Fig. 48.4 Conversion of a
BPD-DS to a Roux-en-Y
gastric bypass
48 Surgical Management ofLeaks
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
447
gastrojejunostomy if the site of the leak is low and there’s enough healthy stomach
to perform it or an esophagojejunostomy if the leak is located proximally in the
stomach.
In order to be able to do this, we would have to perform a distal gastrectomy and
bring up the same alimentary limb that was used for the DI.If a SADI was performed, a conversion to a traditional DS will be required [15].
As expected, the potential for complications are not negligible after these surgeries; extrapolating data from esophagojejunostomy even if performed by experts,
leak rate from that anastomosis could be anywhere between 7.7 and 16% [16].
In the setting of a DS, a stulojejunostomy would be possible (Fig.48.5) by
dividing the biliopancreatic (BP) limb and anastomosing the distal end of it to the
stula and the proximal end at least 50–100cm distal on the same BP limb. However,
despite being feasible, we wouldn’t consider doing this procedure as a rst option
since there are multiple anastomosis and potential spaces for internal hernias that
could lead to even more complications and potentially could affect weight loss and
the metabolic effect of the surgery, since the food will be in contact with bile and
pancreatic enzymes earlier.
Fig. 48.5 Creation of a
stulojejunostomy by
dividing the
biliopancreatic limb
448
A. Shuchleib et al.
48.4 Leak fromtheDuodenoileostomy
As it was mentioned earlier in this chapter, a very early leak could be managed by
repairing the anastomosis, if the tissues are healthy, and not too much inammation
is present. Most of the time, in the acute setting, this will not be possible, and washing out and draining will be the basis of its management.
If the hole is apparent and primary closure is not an option due to the state of the
tissues or the patient, we could also consider placing a T-tube in this area to make it
a controlled stula.
Controlling a stula from a SADI could be more difcult than controlling one
from a traditional DS since bile and pancreatic uid will be constantly passing
through it. This will not only increase the volume of the uid leaking but can give
more inammation due to all the enzymes and the potential irritation from the bile.
One alternative to control the stula better would be converting the SADI to a
traditional DS; this would be done by transecting the afferent limb close to the area
of the anastomosis and anastomosing it distally into the newly created alimentary
limb at least 1m away from the ileocecal valve. Converting the procedure to a
BPD-DS allows for an endoscopic stent to be placed through the leak (Fig.48.6). If
Fig. 48.6 Conversion of a
SADI to a BPD-DS by
dividing the afferent limb
and reanastomosing it
distally with a subsequent
stent placement at the
leaking duodenoileostomy
48 Surgical Management ofLeaks
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
449
a stent is placed over a single anastomosis, this could easily occlude the afferent
limb and potentially burst the duodenal stump.
When the less invasive alternatives fail, conversion to a gastric bypass with a
distal gastrectomy will be required, all the affected area is excised, and a gastric
pouch is confected; since the distal stomach will be in discontinuity, it has to be
excised, and healthy tissues should be used to do the gastric bypass [17].
48.5 Leak fromtheDuodenal Stump
Duodenal stump leak was one of the most feared complications from the open area
when surgery for peptic ulcer disease (PUD) was rampant. At that time, mortality
after a stump leak could have been as high as 77%; luckily as time went by, mortality decreased signicantly [18].
The incidence of this problem is significantly lower than what was reported
in the past because our instruments and staplers are better, we have more
knowledge about the consequences of devascularization the stump, and probably the most important one is that we are operating on healthy tissues unlike
what used to happen in the past when these operations were performed for
either cancer or PUD.
Incidence of this problem is around 1.5% in the setting of a bariatric surgery; the
reason why this happens is either a technical problem like staple malfunction, thermal injury, extensive skeletonization of the stump, and staple line hematoma [7] or
due to a distal obstruction, intraluminal hematoma, adhesions to either other loops
of bowel or the abdominal wall, and narrowing of the distal anastomosis, among
others [18].
Due to the risk of adverse outcomes, management of this type of complications
should be done as early as possible. As with any other acute process, the main treatment would revolve around controlling the leak, managing the infection, and keeping the area decompressed in order for it to heal.
Since this is an uncommon complication from a procedure that is not done so
often, not much is written about the management of these complications in this setting, but we can extrapolate the data.
In cases where the tissues look healthy and the distal obstruction was removed,
it is possible to close the defect or re-staple the stump; in most cases this won’t
be possible, so a tube duodenostomy can be placed. This could be a direct placement of a tube—either a Malecot catheter or even a Foley—in order to control the
spillage. If there isn’t any access to the hole due to the inammation, a lateral
tube duodenostomy can be done on the second portion of the duodenum [19]
(Fig.48.7).
450
Fig. 48.7 Drainage of the
duodenal stump by either
placing a catheter straight
into the leaking site or
lateral into the second
portion of the duodenum
A. Shuchleib et al.
48.6 Leak fromtheJejunoileostomy
This complication is one of the reasons some authors prefer a single anastomosis
procedure, so it can be avoided altogether. As is mentioned before in this chapter,
since this complication doesn’t occur very frequently, and the duodenal switch is
not performed that often, the recommendations for this complication will be extrapolated from gastric bypass data.
The frequency of a leak from a jejunojejunostomy (J-J) is signicantly lower
than on other sites in the GI tract since the small bowel is more forgiving than the
stomach and even more than the esophagus. In a prospective study with over 3000
patients from four tertiary centers, leaks from a jejunojejunostomy happen in the
0.27% [20].
Diagnosis of a J-J leak takes longer to achieve since there won’t be contrast
extravasation; in general the time for diagnosis can double from the time it takes to
diagnose a gastrojejunal leak. Historically, mortality from a J-J leak was as high as
40%, and one of the most important factors was the delay in diagnosis.
48 Surgical Management ofLeaks
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
451
When this complication occurs, conservative management is not advisable as a
general rule. Firstly, anastomosis is mobile and isn’t xed like the gastrojejunostomy, duodenojejunostomy, or the duodenal stump, so placing a radiologic drain
might be hard. Secondly, reaching it with endoscopic procedures will be complicated due to its location. For those reasons we consider that if a leak is diagnosed on
the JI, surgical intervention should be the rst therapy [21].
Laparoscopic exploration can be attempted as long as the patient’s clinical condition allows it, and the rst step would be to revise the area of the leak. If the tissues
look healthy or there was a technical problem, the anastomosis can be repaired primarily. If this isn’t the case, then the anastomosis has to be redone. Since most times
we have enough bowels, the anastomosis can be taken down completely to remove
all the affected tissue, and two anastomoses will be needed to reconnect the patient.
Our preference is to do an end-to-end anastomosis on the alimentary/common
channel in an attempt to restore the original anatomy; we perform this with a handsewn technique. Then we do an end to side anastomosis at least 10–15cm away
from the newly constructed anastomosis also with a handsewn technique. If needed,
two side to side stapled anastomosis can be done; however, if a CT is performed in
the future and the patient is being seen by one other than his surgeon, it might have
the appearance of a dilated bowel resembling an obstruction, and an additional
defect on the mesentery with a potential hernia site will be created.
References
1. Vetter ML, Ritter S, Wadden TA, Sarwer DB.Comparison of bariatric surgical procedures for
diabetes remission: efcacy and mechanisms. Diabetes Spectrum. 2012;25(4):200–10.
2. Sudan R, Maciejewski ML, Wilk AR, Nguyen NT, Ponce J, Morton JM. Comparative
effectiveness of primary bariatric operations in the United States. Surg Obes Relat Dis.
2017;13(5):826–34.
3. Welbourn R, Hollyman M, Kinsman R, etal. Bariatric surgery worldwide: baseline demographic description and one-year outcomes from the fourth IFSO global registry report. Obes
Surg. 2018;29:782–95.
4. Surve A, Cottam D, Sanchez-Pernaute A, Torres A, Roller J, Kwon Y, Dhorepatil A.The incidence of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience. Surg Obes Relat Dis.
2018;14(5):594–60.
5. Surve A, Zaveri H, Cottam D, Belnap L, Cottam A, Cottam S.A retrospective comparison
of biliopancreatic diversion with duodenal switch with single anastomosis duodenal switch
(SIPS-stomach intestinal pylorus sparing surgery) at a single institution with two year follow up. Surg Obes Relat Dis. 2017;13(3):415–22.
6. Rabkin RA, Rabkin JM, Metcalf B, etal. Laparoscopic technique for performing duodenal
switch with gastric reduction. Obes Surg. 2003;13:263–8.
7. Biertho L, Lebel S, Marceau S, etal. Perioperative complications in a consecutive series of
1000 duodenal switches. Surg Obes Relat Dis. 2013;9:63–8.
8. Biertho L, Simon-Hould F, Marceau S, etal. Current outcomes of laparoscopic duodenal
switch. Ann Surg Innov Res. 2016;10:1.
Соседние файлы в папке Библиотека им академика М.И. Перельмана