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How to Manage Sleeve Complications: Surgical Leak and Abscess
Fig. 2 Anterior approach to the RYFJ: Adhesions between the left liver lobe and the sleeved
stomach are divided
467
Fig. 3 Mobilization of the esophagogastric junction: Both the left and the right arms of the diaphragmatic crura are identifible as well as a previously inserted pigtail drain (PTD)
It is not mandatory to close the mesocolon defect around the Roux limb.
Percutaneous closed drainage of the hiatal area is optional. No naso-gastric tube is
required.
E. Chouillard468
Fig. 4 Mobilization of the esophagogastric junction: The Angle of His is to be detached from
the left arm of the crura while making sure the left pleura is not teared
Fig. 5 The fistula site is now completely debrided with well-vascularized, healthy edges, ready
to be anastomosed to the jejunum
How to Manage Sleeve Complications: Surgical Leak and Abscess
Fig. 6 The closing stages of the side-to-side fistulo-jejunostomy using an absorbable runing
suture
469
In the postoperative period, patients had control CT scan with oral contrast
fluid at POD3 before resuming oral intake.
Between January 2007 and December 2018, we managed 221 patients with
SGL. Remission is defined as the absence of clinical or radiological expression of
the SGL site itself or by its consequences (i.e., collection, extravasation, air bubbles). Healing is nothing by a definite remission (i.e., apparent remission + absence
of recurrence). We made this distinction after noticing that apparently “healed”
SGL may recur even many years later (i.e., pregnancy, pancreatitis, malnutrition,
chronic illness) [27]. We could easily understand the situation if we compare a
SGL to type 2 diabetes mellitus. Its remission after bariatric surgery and weight
loss must not be confound with healing.
Of the initial 221 patients, 82 (37.1%) underwent eventually RYFJ. The median
age of SGL in the entire population of patients presenting for RYFJ was 5 months
(range, 0–133). The longest interval between the primary SG and the declaration of the SGL (during a pregnancy) was more than 10 years. In the subgroup
of patients who presented with less than 3-months SGL, the median interval was
16 days (range, 1–88).
Endoscopic treatment was attempted in almost all of the patients, including stenting, IED, clips, glue, sponge, or septotomy. The success rate of the first
E. Chouillard470
attempt at endoscopic treatment was 66.4%. In patients with more than one cycle
of endoscopic treatment, the remission rate rose eventually to 79.1%.
Laparoscopy was attempted in 96.4% of the patients, while 3 patients had
open surgery (i.e., the first 3 patients of the series in 2007). Secondary conversion to laparotomy occurred in only 2 patients (2.5%). The causes of conversion
were poor exposure and bleeding in both cases. The left lobe of the liver was the
major cause of poor exposure. The splenic vessels were the most common cause
of bleeding. The mean operative time was 200 minutes (100–450). Besides two
limited bleedings, no major operative incident was encountered. No splenectomy
had to be performed.
The mortality rate was nil. The post-operative rate of complications was 6.1%
with Only 2 patients had persistent post operative leak (24%). Both eventually
healed in less than 10 days with conservative management.
Long-term analysis of this series revealed that the 10-years control rate of the
SGL was 100% either endoscopic wise (Fig. 7) or as defined by radiology (Fig. 8).
Interestingly, the long-term analysis of the results revealed that the patients who
had RYFJ obtained better long-term weight loss results as compared to those who
had primary SG with no complications (Fig. 9).
4.4 Literature Review of the Remaining Surgical Options
Excluding our experience, less than 20 studies in the literature addressed series
with more than 5 patients who had some form of surgical treatment for patients
with SGL [28]. Almost 60% of these reported patients who had TG (inreality,
these were mainly open Total Degastro-Gastrectomy with Roux en Y Eso-Jejunal
anastomosis). Surprisingly, nearly 10% of authors performed Roux En Y Gastric
Bypass, even for high SGL.
Fig. 7 Illustrative endoscopic endoscopic view of the esophagogastirc junction in a patient who
had previous RYFJ, showing a double oulet pattern (i.e., jejunal and gastric) with no residual
fistula
How to Manage Sleeve Complications: Surgical Leak and Abscess
Fig. 8 Illustrative radiological, CT, coronal view of the upper abdomen in a patient who had previous RYFJ, showing a double oulet pattern (i.e., jejunal and gastroduodenal) with no residual fistula
471
Fig. 9 5-year, total weight loss pattern in patients who had RYFJ for leak after SG as compared
to matched patients who had non-complicated SG at the same period
The laparoscopic approach succeeded in less than 70% of cases with a conversion rate of 6.4% [28]. The most common complication reported for all types of
definitive reconstructive surgeries was another leak (15%), including 37.5% following RYGB, 30% other forms of fistula-jejunostomy, and 8% after TG. The
E. Chouillard472
healing time for a leak following definitive reconstructive surgeries varied between
10 and 165 days. Other complications were reported in 12.3% of patients, including included intra-abdominal abscesses, wound infection, pulmonary embolism,
intestinal obstruction, and miscellaneous other entities.
Mortality was reported in 1% of cases. However, we believe this is
under-estimated since patients may die from complications linked to the SGL
before surgery or more than 30 days after surgery, without being accounted for in
the overall rate.
4.5 Discussion of the Surgical Approach
SGL are more likely to occur in SG patients with distal stenosis, resulting in difficulties in gastric emptying [29]. High intraluminal pressure and low compliance of
the gastric tube may be entertaining causes of SGL [30]. This is why RYFJ seems
to be a pathophysiologically relevant solution since it bypasses both difficulties
(i.e., gastric lack of compliance and endo-luminal high pressure). Additionally,
RYFJ is a surgically conservative option requiring no organ removal (as compared to TG) while not leaving in situ the leak site (as compared to the majority of
RYGBs). However, additional factors are most probably implicated in the occurrence of SGL, including impaired suture line healing, poor blood flow, infection,
and poor oxygenation with subsequent ischemia. All of these items are addressed
either by the preoperative optimization of the patient’s nutritional status or the peroperative surgical debridement during the RYFJ.
Our experience was forged from a heterogeneous panel of techniques used in
SG since patients came from 8 different countries with as many different techniques. However, the management has been eventually homogeneous and implemented by the same multidisciplinary team. Our approach to the management
of SGL has evolved after nearly 15 years of experience with this technique. Our
first SG was performed in 2002 as a part of a duodenal switch and in 2004 as a
stand-alone procedure. Multidisciplinary approach is always indicated with decisions taken jointly by the surgeon, the gastroenterologist, the radiologist, the nutritionist, and the critical care specialist. The patient is closely monitored by a team
of psychologists specialized in obesity management. Depression and suicide ideas
are common among these patients who have been treated, for some of them, for
years with long cumulated hospital stays.
RYGB could still be an option in case of possible gastric remnant. However,
limitations include the risk of leaving the fistula tract in very high localization and
the metabolic consequences of the procedure. Moreover, numerous patients are
reluctant to the idea of having a RYGB. TG is associated to a relatively high risk
of complications related to both the esophagojejunal anastomosis and the duodenal stump. Moreover, the long term nutritional consequences are cumbersome with
malnutrition, weight loss, anemia and the need to readjust the volume and frequencies of meals.
How to Manage Sleeve Complications: Surgical Leak and Abscess
Fig. 10 A proposed algorithm for the management of leak after SG
473
We believe that RYFJ is the most adequate option since it controls the fistula
site in all cases, may preserve the chance of maintaining the SG preferential pathway in the future and avoid the complications of an anastomosis performed on an
ill-vascularized esophagus. The use of a Roux limb type for the anastomosis aims
to allow less tension on the gastrojejunal anastomosis while avoiding the risk of
biliary reflux. Finally, our recent results on long term control of weight loss in
patients with RYFJ are very encouraging.
5 Conclusion
In conclusion, we believe that RYFJ is a safe and confirmed treatment for patients
with persistent SGL. It may even be used as a first option in some patients with
acute SGL.
Figure 10 summarizes our algorithm of management of SGL.
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How to Manage Sleeve Complications Through Endoscopy: Strictures
Thomas R. McCarty and Christopher C. Thompson
1 Introduction
As the total number of individuals within the United States and worldwide with
obesity has continued to increase over the past several decades, so too has the
use of bariatric surgery [1–3]. As of 2013, laparoscopic sleeve gastrectomy has
become the most common type of bariatric surgery performed in the United
States, accounting for more than 50% of all bariatric procedures at this time [4–
7]. Although this increase in the number of laparoscopic sleeve gastrectomy pro-
cedures reflects several advantages over alternative bariatric surgeries, namely a
reduced number of complications with lower morbidity compared to traditional
Roux-en-Y gastric bypass, sleeve-related leaks, de novo gastroesophageal reflux
disease (GERD), and sleeve-associated stenosis may occur [8–10]. In this review,
we will discuss proper identification, classification, and endoscopic management
of sleeve stenosis.
2 Timing, Classification, and Rate of Sleeve Stenosis
While sleeve gastrectomy-related leaks and GERD typically occur early and late
in the post-operative course, respectively, sleeve stenosis and stricture formation may occur are any time post-surgery. After sleeve leaks, stenosis is the most
T. R. McCarty · C. C. Thompson (*)
Brigham and Women’s Hospital, Boston, USA
e-mail: CCTHOMPSON@bwh.harvard.edu
T. R. McCarty
e-mail: trmccarty@bwh.harvard.edu
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_45
477