OBES SURG (2013) 23:676–686 DOI 10.1007/s11695-012-0860-4
ORIGINAL CONTRIBUTIONS
Sleeve Gastrectomy Severe Complications: Is It Always a Reasonable Surgical Option? David Moszkowicz & Roberto Arienzo & Idir Khettab & Gabriel Rahmi & Franck Zinzindohoué & Anne Berger & Jean-Marc Chevallier
Published online: 12 February 2013 # Springer Science+Business Media New York 2013
Abstract Background Laparoscopic sleeve gastrectomy (LSG) is widely adopted but exposes serious complications. Methods A retrospective database analysis was done to study LSG staple line complications in a tertiary referral university center with surgical ICU experienced in treatment of morbid obesity and complications. Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. Interventions consisted in the control of intra-abdominal and general sepsis; restoration of staple line continuity or revision of LSG; nutritional support; treatment of associated complications. Main outcome measures concerned success rates of therapeutic strategies, morbidity and mortality rates, LOS, and time to cure. Results Thirteen patients (59 %) were referred after failure of reoperation (seven fistula repairs were attempted). Three patients received emergency surgery in our center with transorificial intubation and jejunostomy formation. An endoscopic
stent was tried in nine patients but failed in 84.6 % of cases within 20 days (1–161). Seven patients (32 %) necessitated total gastrectomy within 217 days (0–1,915 days) for conservative treatment failure. Procedures under general anesthesia were required in 41 % of cases, organ failure was found in 55 % of cases, and central venous device infection in 40 %. Mortality rate was 4.5 % (n=1). Patients with unfavorable evolution of LSG complications (death or additional gastrectomy) had more previous bariatric procedure (82 % vs. 18 %, p=0.003). Median time to cure was 310 days (9–546 days). Conclusions LSG exposes severe complications occurring in patients with benign condition. Endoscopic stents entail high failure rate. Total gastrectomy is required in one third of the cases.
D. Moszkowicz : R. Arienzo : I. Khettab : G. Rahmi : F. Zinzindohoué : A. Berger : J.-M. Chevallier Assistance Publique-Hôpitaux de Paris, University Paris 5, Paris, France
Introduction
D. Moszkowicz : R. Arienzo : F. Zinzindohoué : A. Berger : J.-M. Chevallier (*) Department of Digestive Surgery, Hôpital Européen Georges Pompidou, 20-40 rue Leblanc, 75908 Paris cedex 15, France e-mail:
[email protected] I. Khettab Department of Radiology, Hôpital Européen Georges Pompidou, Paris, France G. Rahmi Department of Gastroenterology and Endoscopy, Hôpital Européen Georges Pompidou, Paris, France
Keywords Bariatric surgery . Gastric leak . Gastric stenosis . Laparoscopy . Morbid obesity . Revisional Surgery . Sleeve gastrectomy
Bariatric surgery for morbid obesity is associated with stable long-term weight loss and shows a better overall morbimortality decrease compared with conventional medical treatment [1–3]. Laparoscopic sleeve gastrectomy (LSG) was found to be effective in achieving weight loss as well as resolution of comorbidities in severe and super obese patients [4, 5]. Initially developed as the first stage of bilio-pancreatic diversion with duodenal switch for the super-obese or highrisk patients [6], LSG is now most commonly used as a standalone operation. It is considered as an effective technique in achieving up to 60–70 % mean excess weight loss at 3 years [7, 8] and 56 % at 6 years [9]. However, long-term results of LSG and real complication rates are still pending and, in the series of Himpens et al., 26 % of the patients needed a
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complementary duodenal switch procedure for weight failure and 43 % of patients were finally not satisfied with the LSG, reporting more than 20 % of severe reflux or vomiting at 6 years [10]. LSG has mistakenly been considered as technically simple and this fact has contributed to its adoption by a large number of surgeons, making it the most frequent bariatric procedure in France [11]. In 2011, 13,000 sleeve gastrectomies (SGs) were performed, compared with 8,000 gastric bypass procedures and 4,000 gastric bandings. Consequently, LSG severe complications, mainly staple line leak and stricture, are increasingly encountered but are still underestimated and often neglected when a bariatric procedure is discussed for a patient. In fact, gastric leak was reported in 1 % to 20 % of patients, especially after re-operative surgery and can be severe and difficult to manage [12]. We then report here our experience in the management of complicated LSG in patients that have been referred to our university hospital. The aim of this study was to analyze complications following LSG, depending on clinical features, associated morbi-mortality, time-points of detection, management, and cure.
Materials and Methods Patients All patients secondarily referred to the Georges-Pompidou University Hospital with a diagnosis of gastric staple line leak or stenosis after LSG were included in a prospectively maintained computerized database and were reviewed retrospectively. Between January 2004 and February 2012, 22 patients were referred to our institution, including 18 females (sex ratio, 4.5), with mean age at SG 39.5±9.6 years old (range, 20.8–60.3) and initial BMI 41.4±5.7 kg/m2 (range, 30.8–54). They came from 14 different centers in nine different districts, including one university hospital and eight private institutions. We performed in our institution 101 LSG during the same period, but we observed no leak or stenosis. In total, 59 % of patients (n = 13) had further bariatric procedures: eight (36.3 %) had previous gastric banding, one (4.5 %) had previous duodenal switch, one (4.5 %) had previous vertical banded gastroplasty with secondary leak and managed in our institution for late stenosis, one (4.5 %) was referred for complicated Roux-en-Y gastric bypass (RYGB) secondary to LSG complicated by leak 9 months ago, and two patients (9 %) presented with gastric leak after synchronous duodenal switch. Definitions A gastric leak was defined in accordance with admitted criteria [13] and was considered as “acute” if observed within 7 days of LSG, “early” if observed 1–6 weeks from LSG, “late” if
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observed after 6 weeks, and “chronic” if has lasted >12 weeks [14]. We considered as gastrocutaneous fistula a leak of the gastric luminal content from the staple line to the abdominal wall, through the previous drain incisions or the laparotomy/ laparoscopy scares. We considered as eso-gastric fistula a leak of the staple line into the peritoneal cavity, collecting near abdominal organs and emerging through surgical or radiological inserted drains. We defined a gastric staple line stenosis as immediate, if the gastrectomy was executed too close to the lesser curvature with complete or almost complete horizontal gastric division and immediate symptoms of stenosis, or as delayed, after initial good functional results. Data Acquisition Information was obtained from the clinical charts of the patients and, if possible, by interviewing the surgeons who performed the LSG and initially treated complications. The following variables were gathered and studied: gender, age, and body mass index (BMI) at the time of LSG, previous or synchronous associated bariatric procedures, intraoperative incident, employment of staple line reinforcement suture and drainage, postoperative symptomatology, studies employed for leak/stenosis diagnosis and delay between LSG and the confirmation of complication, location of the leak/stenosis, initial treatment approaches in outside institution, delay between diagnosis and university center referral, time required for healing from LSG and from university center admission, total postoperative length of stay in university center, and number of admissions until cure. Related morbidity was considered according to the Dindo classification [15]. The mortality rate was calculated. General Principles of Management After patient admission, we followed the general principles of management of eso-gastric leak or stenosis, according to the International Sleeve Gastrectomy Expert Panel Consensus Statement [14]: control of intra-abdominal and general sepsis by antibiotics, percutaneous image guided drainage of abscess, and/or additional surgical lavage and drainage; endoscopic restoration of staple line continuity or revision of LSG in case of prolonged evolution; nutritional support with nil by mouth and enteral or parenteral nutrition; treatment of associated complications. Statistical Analysis Results are presented as the median (range) or mean±SD for continuous variable and number (percentage) for categorical variables. Univariate logistic regression analysis using the χ2 test or t test when appropriate was used to estimate the relationship between the risk for unfavorable evolution, i.e.,
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Fig. 1 A 45-year-old female with previous gastric banding, band removal for slippage, and sleeve gastrectomy, presented with gastric fistula, perisplenic abscess and wound abscess revealing a complex gastrocutaneous fistula (fistulographies: a several routes visible on b).
c large gastrocutaneous fistula, abscess in the splenic hilum, pylephlebitis in splenic and intrahepatic portal veins. The patient died 2 days after reoperation
death or necessity for radical surgery leading to the revision of stomach anatomy (total gastrectomy or gastrojejunostomy) and several variables, including variables associated with increased postoperative morbidity such as sex, age, BMI, and previous or synchronous additional bariatric procedure. Complementary treatments for the management of complications and reoperation in primary center were studied as well. A p value of 0.05 or less was considered as statistically significant.
Results
Fig. 2 A 58-year-old female had LSG associated with biliopancreatic diversion and consecutive gastric leak, presented with severe hematemesis and hypovolemic/septic shock related to a false aneurysm of the splenic artery ruptured near the gastric pouch (white arrow, (a, b)), successfully treated by embolization of the splenic artery (white arrow (c, d): pseudoaneurysm, grey arrow: active bleeding)
Initial Management In their institutions, practice was not homogeneous between surgeons as reinforcement of the staple line, methylene blue test, and early postoperative radiologic evaluations were not systematic. Calibration with an intragastric bougie was used in all but two patients, who were referred with complete or
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Fig. 3 A 40-year-old female patient with previous sleeve gastrectomy and synchronous biliopancreatic diversion with duodenal switch presented with gastric leak. a CT scan showing a subphrenic abscess. b Percutaneous drainage under CT scan. c, d Gastropleural fistula with contrast fluid in the pleural cavity (white arrow). e, f Endoscopic
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placement of a 17-cm-long esophageal prosthesis, shown in correct position, without residual abscess. g Urgently hospitalized for acute respiratory failure and pneumonia: left gastropleural fistula recurrence (white arrow), finally necessitating total gastrectomy and eso-jejunal anastomosis, in spite of the replacement and repositioning of the stent
almost complete horizontal gastric section. However, intraoperative drainage of the staple line and nasogastric tube insertion was mentioned by the outside surgeon in all patients. Reported postoperative symptoms related to gastric leak were more frequently epigastric pain, fever >37.5 °C, tachycardia >120 bpm, leukocytosis >10,000/mm3, and CRP >10 mg/L. The median time elapsed after LSG was 4.5 days (range, 1–11; mean±SD, 5.3±4 days) for fistula diagnosis and 5.5 days (range, 1–235; mean±SD, 61.7± 115.5 days) for stenosis diagnosis. Diagnosis was suspected and/or confirmed by contrast swallow and upper abdominals X-ray series or CT scan, methylene blue test injection throughout nasogastric tube, endoscopy, percutaneous fistulography, and/or at exploratory laparoscopy or laparotomy if reoperation was required. Thirteen patients were referred after at least one emergency reoperation leading to the confirmation of the gastric leak. Seven fistula repairs by re-suture were reported and resulted in systematic failure. Fig. 4 A 30-year-old female. Total food intolerance after LSG necessitating parenteral nutrition. Three gastroscopies have concluded to correct passage down to the duodenum. Upper GI series confirming the twist of the gastric tube. Whirl of the spiral (white arrowhead)
Management After Referral (Figs. 1, 2, 3, 4, 5, 6, 7) Patients were referred after a median delay of 16 days (range, −2 to 272; mean±SD, 72.3±104.2 days) after leak
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Fig. 5 A 21-year-old male, sleeve gastrectomy complicated with complex gastrobronchial fistula. a, b CT scan with oral contrast study, before and after percutaneous drainage, showing communication
between the gastric pouch and a bronchial tube in the lower left lung lobe. c Coronal reformation confirming the passage of the contrast agent from the gastric pouch to the pleural cavity and bronchial tubes
diagnosis and 74.5 days (range, 4–106; mean±SD, 514.2± 927.4 days) after stenosis diagnosis. Patient presentation is summarized in Table 1. Two patients were referred with suspicion of leakage and were operated on in emergency in our institution (no. 1, 7). One patient needed complementary emergency reoperation for persistent leakage responsible for peritonitis and septic shock (no. 10). These last three patients received transorificial intubation with a T-tube, peritoneal lavage and drainage, and feeding jejunostomy formation. Eleven patients (50 %) necessitated percutaneous drain insertion for intra-abdominal abscess or gastro-pleurobronchial fistula. Delayed endoscopic management consisted in the placement of 13 covered stent in nine patients (range, 1– 3). Six patients received a stent due to uncontrolled drain output over time and/or recurrent collections, and three patients received a stent for persistent stenosis. It led to fistula persistence in five cases (38.5 % of stents) (Fig. 3), early migration in three (23 %), intolerance with pain and vomiting in three (23 %), and success in two (15.4 %). The failure rate
after stent use was 84.6 % and resulted in ablation within 20 days (range, 1–161). An endoscopic sequential strategy was employed including a stent, followed by placement of an Over-the-Scope (Ovesco©) clip and sealant in two patients (no. 19 and 22), and a stent followed by an Ovesco© clip in three (no. 11, 12, 21). It resulted in cure in three of five (60 %). Six patients finally necessitated total gastrectomy with esojejunostomy after a median delay of 530 days (range, 86– 1,915 days) due to prolonged leak or stenosis evolution and failure of nonoperative measures. One patient had immediate total gastrectomy after complete gastric division and was referred for eso-jejunal leak (no. 9). Three patients necessitated complementary gastric resection and gastrojejunostomy-en Ω after within 174 days (range, 9–410 days), two after almost complete gastric division at LSG (no. 7, 22), and the other after prolonged evolution of an esogastric leak after duodenal switch (no. 21) (Table 2). The total number of admissions for completion of procedures, lengths of stay, and time to cure are summarized in Table 3.
Fig. 6 A 42-year-old female had sleeve gastrectomy and synchronous biliopancreatic diversion with duodenal switch with postoperative peritonitis requiring reoperation, drainage, and suture of the gastric leak. CT scan with injection and oral contrast allowing opacification of a large chronic fistula (a, thick arrow), involving a 6-cm subphrenic abscess and an abscess into the spleen (thin arrows, b)
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Fig. 7 A 21-year-old male referred 6 days after LSG for total food intolerance and suspicion of gastric stenosis at upper GI series. Explorative laparoscopy confirmed almost complete gastric division by placing first stapling too close to the lesser curvature (black arrow)
Morbi-mortality Associated complications and complex fistula pathways were encountered in 86.3 % of the patients (n=19). In total, 39.3 % of the patients (n=9) presented with central venous device infection during the postoperative period, necessitating antibiotics and device replacement. Intensive care unit was required in 63.6 % of patients (n=14) for septic shock, respiratory or renal failure, or surveillance after total gastrectomy. Classification of surgical complications of LSG according to Dindo was: grade 3B: n=9 (41 %); 4A: n=1 (4.5 %); 4B: n = 11 (50 %); and 5: n = 1 (4.5 %). The mortality rate was 4.5 %, as one patient died 53.5 months after the LSG from multiple septic complications (Table 1: no. 1; Fig. 1). The univariate analysis revealed that LSG as a redo bariatric procedure caused significantly higher risk of unfavorable evolution (death or radical surgery) than primary LSG (p=0.003, Table 4).
Discussion This is to our knowledge the largest series of LSG surgical complications to be published from a referral center in bariatric surgery. These complications such as chronic leak and stenosis were found to entail a high related morbidity rate, a substantial mortality rate (4.5 %), and a challenging and prolonged management. As a unique procedure, LSG is extensively proposed but seems to entail considerable morbidity in more than 12 % of patients, such as, leakage, stenosis, or bleeding. For example, a 7 % leak rate was reported in a multicentric database and ranged from 0 % to 7 % in a literature systematic
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analysis on 4,888 patients [10, 16, 17]. The mean stricture rate is around 0.5 % [17]. In the study of Weiner et al., mortality following LSG (0.4 %) was shown to be higher than after gastric bypass or banding (50 kg/m2, male sex, age >55 years old [17], but also revisional surgery. Although a few studies consider reoperative bariatric surgery as feasible and safe [19, 20], it is classically associated with significantly higher operative mortality (around 2 %) and morbidity (33 % to 62 %) than in primary procedures [21, 22]. This higher morbidity is mostly related to anastomotic leak that occurred in 13.2 % (n= 20/151) of patients in a recent series of bariatric reinterventions. [23] As we confirmed in all patients of this series, gastric leak occurs at the proximal portion of the staple line in almost 90 % of cases [17], where the gastric muscular layer is anatomically thinner. LSG as a revisional procedure for failure of previous restrictive surgery was evaluated in a small series of selected patients [24] but has not proved its tolerence and efficiency. We confirmed here a worse evolution of LSG complications following a preceding gastric operation, advocating for the choice of an alternative safer bariatric procedure in case of failure of a primary operation such as banding or vertical banded gastroplasty. Early reintervention after complicated LSG is associated with better results and prompt cure [17] and is mandatory in the case of postoperative alert symptoms such as tachycardia and fever. In this study, the median delay between LSG and fistula diagnosis confirmation was 4.5 days (1–11), but all patients presented with alert symptoms within the first 7 days after LSG. As recommended elsewhere [12, 25], leak resuture on ischemic gastric walls should be avoided especially after the third day, leading to systematic failure in this series. We, as others [26], advocate transorificial intubation with Ttube and intraperitoneal drain placement in the concerned area. In fact, the alkaline leakage associated with various degrees of peritonitis jeopardizes the possibilities for spontaneous leak closure. The T-tube ensures the control of the leak and to have a controlled gastrocutaneous fistula, preventing deep infectious complications such as abscess and complex fistula associated with primary suture. The T-tube is removed after the patient has a negative upper GI study and tolerates oral intake with a closed T-tube. This strategy led to constant success in this series, with shorter times-tocure. As we observed, a 40 % rate of central venous device infection in these patients requiring prolonged total parenteral nutrition, we recommend systematic feeding jejunostomy formation during reoperation (Table 3). Feeding
Age at LSG (year)
45
58
40
50
42
37
39
35 36
60
46
43 37
30 36 21
38 34
36
Patient no./sex
1/F
2/F
3/F
4/F
5/F
6/F
7/F
8/F 9/F
10/F
11/M
12/F 13/F
14/F 15/F 16/M
17/F 18/F
19/M
138
95 92
106 90 155
99 140
140
98
107 120
84
138
96
89
135
101
120
39
41 36
40 36 46
36 54
41
42
41 47
31
49
42
37
47
36
43
– – – – – –
– – – – AGB –
–
–
–
–
– GBP
– –
– –
–
AGB
VBG –
Complete gastric division, eso-gastric leak Eso-gastric leak
–
–
Septic shock Subphrenic abscess, septic shock
Generalized peritonitis, subphrenic abscess Generalized peritonitis, subphrenic abscess Generalized peritonitis
Subphrenic abscess
4B
4B 4B
4B 3B 3B
3B 4A
4B
4B
4B 4B
3B
3B
4B
3B
No. 2
No. 1
Figure
–
–
–
– –
–
–
Cure
–
Total gastrectomy – Cure –
Cure No. 4 Total gastrectomy Cure No. 5
Cure Cure
Cure
Cure
Total gastrectomy – Total gastrectomy –
Omega loop
Cure
Total gastrectomy –
Cure
Total gastrectomy No. 3
Cure
Death
Dindo-Clavien Evolution complication grade
5 Generalized peritonitis, septic shock, subphrenic abscess, pylephlebitis, liver failure, death Ruptured splenic artery 4B pseudo-aneurysm, hemorrhagic shock Septic shock 4B
Associated complications
Complete gastric division with bougie section, immediate total gastrectomy, eso-jejunal leak Eso-gastric leak Generalized peritonitis, septic shock Gastrocutaneous leak Generalized peritonitis, septic shock Gastrocutaneous leak Subphrenic abscess Gastrocutaneous leak Subphrenic abscess, liver abscess, septic shock Stenosis (gastric twist) – Upper stenosis – Subphrenic abscess Gastrocutaneous leak, gastropleural fistula, gastrobronchial fistula Multiple stenosis – Gastrocutaneous leak Generalized peritonitis, septic shock Gastrocutaneous leak Generalized peritonitis, septic shock,subphrenic abscess
Eso-gastric leak
–
Eso-gastric leak, gastropleural fistula Eso-gastric leak, bougie section Eso-gastric leak
Eso-gastric leak
Gastrocutaneous leak
AGB
–
DS
– AGB
DS
GBP
AGB
AGB
Previous Associated Gastric abnormalities Weight at BMI at bariatric LSG (kg) LSG (kgm−2) bariatric procedure procedure
Table 1 Referral motivations, associated complications, and final evolution in 22 patients referred for LSG complications
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683 No. 7
No. 6
Figure
OBES SURG (2013) 23:676–686 Table 2 Procedure performed in the entire population
Omega loop
Omega loop
3B
3B – – 41 21
129 22/M
Stenosis (almost complete transverse gastric section)
Subphrenic abscess, spleen abscess – Eso-gastric leak DS AGB 39
Eso-gastric leak, – 40 AGB Total – gastrectomy
20/F 37 97 gastroSubphrenic abscess, 3B pleural colonicperforation fistula 21/F 42 103
Age at LSG (year) Patient no./sex
Table 1 (continued)
Previous Associated Gastric abnormalities Weight at BMI at bariatric LSG (kg) LSG (kgm−2) bariatric procedure procedure
Associated complications
Dindo-Clavien Evolution complication grade
Management Initial outside procedures Laparoscopic lavage and drainage Laparoscopic fistula repair Fistula transorificial intubation Open lavage and drainage Operative drains maintained Endoscopic dilatation of stenosis Eso-jejunal anastomosis after complete gastric division Procedures in university center Emergency care after referral Fistula transorificial intubation Arterial embolization of pseudo-aneurysm Delayed management Total gastrectomy Gastrojejunostomy en-Ω after gastric division Endoscopic covered stent Endoscopic Ovesco© clip Endoscopic sealant Endoscopic dilatation of stenosis Image guided percutaneous drainage of subphrenic abscess Image guided percutaneous drainage of gastrocutaneous fistula Trans-phrenic drainage of gastro-pleurobronchial fistula
n=22 (%)
7 7 1 5 2 2 1
(31.8) (31.8) (4.5) (22.7) (9) (9) (4.5)
3 (13.6) 1 (4.5) 6 (27.2) 3 (13.6) 13 in 9 patients (40.9) 5 (22.7) 2 (9) 1 (4.5) 8 (36.3) 2 (9) 1 (4.5)
jejunostomy also ensures to avoid an increased proximal flow that could rise the leakage output. The use of endoscopic stent in management of leaks after LSG was described although there is still no evidence base for the effectiveness of its employment [27]. However, endoscopic strategy for management of LSG complications was assessed in our study with a high failure rate. Tan et al. reported a low 50 % success rate with patients necessitating precipitate removal [25]. In fact, as we found in this study, fistula pathways are often complex with multiple or large orifices, strong fibrosis and epithelia reformation, explaining these high failure rates. However, with an analogous strategy from an expert center in endoscopy, involving consecutive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with covered colorectal stent, and then closure of the residual orifice with clips or sealant in 27 selected patients, Bège et al., reported a 59 % migration rate and the necessity of 4.4 endoscopies per patient [28]. In particular, the Over-The-Scope-Clip (Ovesco©) gave preliminary encouraging results in the treatment of anastomotic leakage [29, 30]. Additional prospective studies are, however, needed to confirm the interest of these procedures and advances in devices development are awaited.
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Table 3 Lengths for LSG complications management in the entire population LSG management steps
Fistula (n=18)
Stenosis (n=4)
Mean±SD
Median (range)
Mean±SD
Median (range)
Total postoperative LOS in university center Number of university center admissions for completion of procedures Duration between university center admission and cure Duration between SG and cure
59.2±44.4 2.2±0.9 120.4±110.4 203.6±165.7
39 (12–153) 2 (1–4) 97 (13–412) 134.5 (41–546)
31.25±20.4 2.5±1.3 109.2±101.8 686±969.6
26 (13–60) 2 (2–4) 106.5 (3–221) 305 (9–2,125)
In the case of chronic leak or stenosis and failure of conservative management, further radical surgical solutions must be discussed. LSG conversion to a gastric bypass was described for weight failure but, in the case of gastric leak, the orifice is often located at the upper staple line, making dissection of the
fibrotic cardial area difficult. The use of a Roux limb brought to the esophagogastric junction and anastomosed side-to-end to the fistula was described [31], but this procedure entails the same technical difficulties than the bypass and was only the object of rare case reports. A total gastrectomy was performed in almost one third of our patients, but we observed esojejunal leak leading to multiple reoperations in one case and total gastrectomy is not an acceptable procedure in the particular case of obesity. As postoperative fibrosis of the cardial area often makes surgical redissection almost impossible, these first three alternatives are habitually abandoned. Finally, directed fistulization by surgical or radiologic transorificial intubation is adopted, leading to the formation of a prolonged gastrocutaneous fistula, theoretically ensuring organ preservation. This could explain a median time to cure close to 1 year in this series. We report here especially long periods of management before cure, but little detailed information is available in the literature concerning these delays. It may be linked to the misfit initial management in outside centers. In the study of de Aretxabala et al., the leak closed in all eight in-patients with a shorter healing time ranging from 21 to 240 days, thanks to a standardized management with T-tube gastrostomy and feeding jejunostomy formation [32]. In order to prevent these dreadful complications, even if no recommendation can be formulated from this study regarding the weak number of subjects, technical key points, that have been addressed in consensus statements, are mandatory during LSG formation [14]: correct calibration with bougie size >36– 40 Fr; special attention to the first stapling fire for prevention of transverse gastric division; gentle and symmetric lateral traction on the pouch during stapling for twist and stricture prevention; cautious last stapling fire employing loads with shorter staples than on the lower stomach, as it is performed in the delicate region of the esophago-gastric junction; oversewing the staple line with bougie in place or other reinforcement (although this point is still subject to debate); methylene blue test; retrogastric drainage, and nasogastric tube placement. In our institution, only super obese patients with unfavorable anatomy (short and fat mesentery causing difficulty in raising the bowel loop without tension) undergo a first-stage LSG. An eventual second-stage omega loop gastric bypass, also called mini-gastric bypass (MGBP), is performed in the case of
Table 4 Risk factor analysis for unfavorable evolution of the complications of LSG Population (n=22) Sex Male Female Age
