Surgery for Obesity and Related Diseases ] (2015) 00–00
Original article
Laparoscopic total gastrectomy as an alternative treatment to postsleeve chronic fistula Almino Cardoso Ramos, M.D.a,*, Manoela Galvão Ramos, M.D.a, Josemberg Marins Campos, M.D., Ph.D.b, Manoel dos Passos Galvão Neto, M.D.a, Eduardo Lemos de Souza Bastos, M.D., Ph.D.a a
Gastro Obeso Center, Advanced Institute for Digestive and Bariatric Surgery, Sao Paulo, Brazil b Federal University of Pernambuco, Recife, Brazil Received June 27, 2014; accepted October 26, 2014
Abstract
Background: Sleeve gastrectomy (SG) has become a very common 1-stage procedure in bariatric surgery. Postsleeve chronic fistulas could be one of the possible complications and represent a true challenge for the surgeons. After the failure of more conservative treatments, including surgical and endoscopic approaches, laparoscopic total gastrectomy (LTG) could be an alternative treatment proposal. The objective of this study was to evaluate outcomes of patients who underwent laparoscopic total gastrectomy for the treatment of postsleeve chronic fistula. Methods: Retrospectively review the data from patients after LTG for postsleeve chronic fistula who had failed in all previous treatment attempts with a combination of conservative, endoscopic, and/or surgical approach. Results: From January 2008 to December 2012, 12 patients underwent LTG. Mean time from SG to LTG was 16 months (ranged from 6 to 30). All patients had undergone several previous treatment attempts, including endoscopic techniques (fibrin glue, clips, pneumatic dilation, and stents) and surgical procedures for abscess drainage. Surgical time ranged from 4 to 7 hours with a mean hospital stay of 6 days. Complications occurred in 2 patients (17%) with 1 revision as a result of an intestinal occlusion. There were no conversions to open surgery, anastomotic leaks, or deaths. Conclusions: LTG was feasible in the management of postsleeve chronic fistulas recalcitrant to other treatment approaches with a few complications and high rate of resolution. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Postoperative complications; Anastomotic leak; Gastrectomy
Laparoscopic sleeve gastrectomy (LSG) was initially proposed as part of a combined approach in association with duodenal switch and also as a staged strategy as the first-step surgical procedure for super-obese and high-risk obese patients [1]. Now it has been most commonly accepted as a stand-alone surgical technique becoming more popular all over the world [2–5]. * Correspondence: Almino Cardoso Ramos, M.D., Gastro Obeso Center, Advanced Institute for Digestive and Bariatric Surgery, Rua Barata Ribeiro, 237 Sao Paulo, SP, Brazil. E-mail: [email protected]
Considering the increasing worldwide numbers for LSG in recent years, a higher number of complications can also be expected. The gastric leak and subsequent fistula could possibly be considered the most dreaded complication, with an occurrence of approximately 2% [6–12]. The leak can be present all along the staple-line, but when it happens close to the esophagogastric junction, at the angle of His, the treatment could be a true challenge for the surgeon. Unfortunately, this is the most common site of the leak [13]. A number of therapeutic modalities have been proposed to handle postsleeve fistulas, including surgical or percutaneous drainage [14]; endoscopic therapy with clips, dilation,
http://dx.doi.org/10.1016/j.soard.2014.10.021 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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A. C. Ramos et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
and stents [15–18]; and early resuturing of the leak [19]. When these options fail, surgeons have to resort to more aggressive surgical revisional options, such as converting the sleeve to Roux-en-Y gastric bypass (RYGB) or Roux limb drainage placement at the fistula site [6,20–22]. Laparoscopic partial or total gastrectomy may be the last and most radical options to be offered for selected cases. Total gastrectomy has already been used successfully according to reports of a few cases in the effort to correct the staple-line postsleeve fistula [23–28], but unfortunately, the very small number of patients has not offered enough data to evaluate the safety profile and efficacy of this proposition. The aim of this study is to present a case series of patients who required laparoscopic total gastrectomy (LTG) as treatment for postsleeve chronic fistula after previous failed conservative, endoscopic, or surgical management. Methods The treatment records of patients undergoing LTG for chronic fistula after LSG were reviewed. All consented and signed a form allowing medical records to be reviewed and published with previous approval of the local review board. Preoperative upper endoscopy, computed tomographic (CT) scan, and gastrointestinal radiographic series were performed to evaluate the site and path of the fistula and possible stricture or other sleeve-associated anatomic abnormalities. Total parenteral nutrition or enteral feeding were indicated in every case to improve nutritional status for the procedure. Previous treatment sessions of endoscopic management involving clips, fibrin glue, high-pressure pneumatic balloon dilation, and coated self-expanding stent placements and operations to drain abscesses and improve septic conditions were performed in all patients before the gastrectomy by interventional radiology, endoscopy, and laparoscopic approaches. Only after the failure of all of these was the LTG performed as a surgical attempt to resolve the clinical situation by removing the chronic fibrotic and damaged tissue, relocating the staple line, and performing an anastomosis in healthy tissue, looking for better chance of healing. Surgical technique LTG was undertaken in the split-leg position with the operating surgeon standing between the patient’s legs. Pneumoperitoneum was created with an optical bladeless trocar and 4 more surgical ports were inserted, using the previous incisional sites when possible. The lesser curvature and anterior wall of the remnant-sleeved stomach were, in general, severely adhered to the left lobe of the liver and abdominal wall, and careful removal of adhesions was done with hook electrocauterization, regular scissors, and harmonic shears. Dissection of the gastric sleeve greater curvature, lesser sac, hiatus, and esophagus was performed, and the vessels of the stomach were identified, divided, and clipped. The first
portion of duodenum was dissected and then stapletransected 2 cm below the pylorus using a linear stapler device with a 45-mm white cartridge. After full mobilization of the abdominal esophagus, it was transected with a 45-mm blue cartridge linear stapler. The biliopancreatic limb was measured from the ligament of Treitz for 50–60 cm; the intestinal limb was anastomosed to the esophagus (E-J anastomosis) with a 45-mm blue cartridge linear stapler and sutured over a 32F bougie with polydioxonone 3-0 (PDS®, Ethicon Endo Surgery, Inc.) 3-0 extramucosal running suture with no calibration. A side-to-side jejunojejunostomy was constructed with the alimentary limb at 100 cm with a 45-mm white cartridge linear stapler and closed with an extramucosal 3-0 PDS running suture. The Petersen and mesenteric openings were closed with nonabsorbable, running Ethibond 2-0 suture, and a methylene blue leak test was done. Then the Billroth II like limb was converted into a Roux-en-Y by dividing the limb connecting the E-J and enteroanastomosis with a 45-mm white cartridge linear stapler. A drainage tube was placed around the E-J anastomosis and the duodenal stump; fascial incisions 410 mm and the skin incisions were closed. All the operations were done in a high-volume bariatric center by the same bariatric surgeon, who performed approximately 1000 bariatric procedures each year. Results Over a period of 5 years (from January 2008 to December 2012), the charts of 12 patients (n = 12; 5 male patients) with a mean age of 44.5 years (range 18–62) undergoing LTG for esophagogastric junction chronic fistula after LSG were included. All but 1 patient were referred cases. The average total operative time of these procedures was 5 hours (range 4–7). The previous number of surgical interventions before the total gastrectomy ranged from 1 to 6 (mean 4) per case. Also patients were submitted to endoscopic attempts to close the fistula with an average of 5 sessions (range 3–8). Time from LSG to LTG ranged from 6 to 30 months (mean 16 mo). Patients had a postoperative length of stay of 6 days (range 5–12) and were able to walk on the second postoperative day. A liquid diet was given to most of them on the third postoperative day. There were no deaths, and complications occurred in 2 cases, with pneumonia in 1, treated with antibiotics and pulmonary physiotherapy, and an intestinal occlusion in another, caused by partial bowel herniation at the site of 1 of the 12-mm trocars (Richter hernia). This last patient required reoperation on the fifth postoperative day with good recovery. Demographic data and other clinical features of the patients are summarized in Table 1. Discussion The sleeve gastrectomy (SG) was first described as an effort to improve the results of the classic biliopancreatic
Laparoscopic Total Gastrectomy / Surgery for Obesity and Related Diseases ] (2015) 00–00 Table 1 Demographic data and clinical features from all 12 patients undergoing LTG for chronic fistula after sleeve Patient Age Gender Previous Time Sessions of Operative Length (yr) surgery from endoscopy time (hr) of stay LSG therapy* to LTG (mo) 1 62 2 54 3 48 4 35 5 42 6 18 7 59 8 50 9 32 10 47 11 37 12 52 Mean 44.5
M M M F F F F M F M F F
6 5 3 1 2 5 1 2 6 4 5 6 4
18 12 14 11 13 18 7 6 30 20 24 22 16
8 3 6 6 5 8 5 4 4 5 4 6 5
7 4.5 5 6.5 5. 5.5 4 6 5.5 5 4 5 5
12 5 6 5 7 10 6 5 7 6 5 6 6
Abbreviations: LSG ¼ laparoscopic sleeve gastrectomy; LTG ¼ laparoscopic total gastrectomy; M ¼ male; F ¼ female.
diversion (BPD) [29] and some years later was reported by laparoscopy [30], as a part of the BPD as well. At first, LSG was mainly performed as a first-stage in high-risk morbidly obese patients [31], but more recently, based on the good results published as a bariatric or metabolic procedure, it has gained popularity as a stand-alone surgery [32–34]. Currently, LSG is recognized both as a primary bariatric procedure and as a first-step practice in high-risk patients as part of a planned staged surgical strategy [4]. Reflecting this fast acceptation and growing number of LSG procedures, an increasing rate of complications would also be expected, especially because the LSG has some potential technical pitfalls and a lot of surgeons who perform it are still novices in bariatric surgery, within the “LSG learning curve.” LSG complications have been reported in almost one quarter of the procedures [35]. Postsleeve gastric leaks are the most dreaded complication and very often can be the source of major morbidity, long length of stay, high costs, and mortality risk. Leaks occur when the gastric contents pass through the staple line because of its insufficient closure or rupture. Studies are not conclusive about the reasons for leak, but it seems that the high pressure inside the gastric tube and healing problems in the angle of His area are the most important related factors. When these leaks become chronic, producing an epithelialized path, a fistula is formed, which may not close spontaneously and may become refractory to the conventional clinical treatment. In general, these cases demand more time to resolve and require treatment with specialized endoscopic and radiologic approaches or even complex surgical revisions. In this situation, the patient is often required to be referred to a center of excellence in bariatric
3
surgery for skilled therapy because these fistulas are associated with a significant risk of death [36]. The most recent position statement of the American Society for Metabolic and Bariatric Surgery (ASMBS) corroborates this concern about postsleeve staple line leaks and reports an occurrence in 1%–3% of patients in large published series [4]. It may be true that most of the leaks are very low volume, transient, asymptomatic, and close spontaneously. Therefore, the actual incidence of the leak may be greater than reported. On the other hand, some leaks may require a wide range of therapeutic modalities, especially those that occur close to the esophagogastric junction. The first step in postsleeve leak management is a quick and correct diagnosis. All suspected or diagnosed patients should receive the same initial care, with fluid replacement, nutritional support, antibiotics, and appropriate targeting of the leakage abscess. Radiologic percutaneous or laparoscopic drainage are generally the best initial options. Surgical closure by resuturing the hole of the leak may also be tried but usually fails [37], especially in late leaks [19]. The setting of appropriate surgical drainage with very aggressive nutritional support may lead to the leak healing in some cases [38], and this option is especially valuable in hospitals without expertise in bariatric surgery. After clinical stabilization, the available therapies can range from a simple clinical observation for spontaneous healing, endoscopic assessment, and surgical drainage to more radical surgery options such as total gastrectomy. In regard to endoscopic therapy, including an emerging list of less invasive alternatives to surgery, very fashionable currently, it is very important to notice that postsleeve fistulas are usually the most difficult to heal in comparison with RYGB [39], maybe because of the higher pressure within the stomach in sleeve [40]. The true effectiveness of endoluminal therapy in postsleeve fistula may not have been totally proven because the studies are based only on case series, with few numbers, including a very heterogeneous group of patients, and do not usually report important details with no possibility of randomization. In the authors’ opinion, however, endoscopy should always be attempted before radical surgery treatment, because successful leak closure with pneumatic dilation and the use of selfexpandable stents is almost 90% [41]. For this reason, in the present series, all the patients undergoing LTG first had endoscopic treatment, with sessions ranging from 3 to 8 (mean 5), including the use of fibrin glue, clips, balloon pneumatic dilation, and double-coated metallic stents. In attempt to increase the success rate of drainage and endoscopic management, it is important to ensure the absence of sleeve-associated strictures or rotation [42]. The current available options for the radical surgical treatment of the postsleeve chronic fistula include a Roux limb placement at the site of the leak, conversion from SG to RYGB, and partial or total gastrectomy [27]. In the present series, the LTG was chosen. Even if this operation could be
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considered technically complex, it may represent the patient´s last possibility for cure. The authors believe that it should only be done at centers with extensive experience in laparoscopic revisional surgery. The use of Roux limb placement can be undertaken as early as 4 weeks after the leak has been diagnosed in the effort to save costs [21,22]. Beyond the great technical difficulty in performing the anastomosis between the leak area with very thick, fibrous, and inflamed tissue and the jejunal limb, this operation usually promotes a double alimentary route and the longterm clinical outcomes are uncertain. It seems logical to assume this will compromise the intended restrictive effect of the SG affecting the final weight loss. Conversion to RYGB could also be a successful strategy based on the fact that gastric bypass leaks tend to have better outcomes than those after SG, probably as a result of relief of pressure in the sleeve. However, this may be associated with complications in the new staple line and gastrointestinal anastomosis, and the risk of not achieving closure of the leak in the stomach pouch should be considered. Also, the final weight loss could not be predictable. Although postoperative leaks after total gastrectomy have been reported [27], based on the reports of successful total gastrectomy to treat chronic postsleeve fistula (associated with duodenal switch or not) [23–28], it was decided to perform LTG as the last surgical option. In the present series, there was no mortality and no major technical complications related to this supposed high-risk esophagojejunal anastomosis. All of our patients underwent total gastrectomy with laparoscopic approach. Although a laparotomic approach might seem to be less difficult with the dense adhesions from the prior surgery, the laparoscopic approach, even more laborious, can benefit patients when performed by trained surgeons with faster and more comfortable recovery. To the best of the authors’ knowledge, this has been the largest LTG case series published so far. The most important advantage of this technique is to work with healthy tissue with no inflammation or fibrosis, because the diseased sleeved stomach and the fistula tract will be removed. The anastomosis can be done between the normal esophagus and jejunum with much more predictable results. The main limitation to support the conclusions may be the type of study performed: a retrospective case series. To compare with other surgical options, a randomized, multicenter study is required, but this is almost impractical. Because of the unpredictability of the occurrence of cases, this type of trial would require a long study period to enroll an adequate number of patients. Conclusions LTG is a feasible and effective treatment option for refractory postsleeve chronic fistula, but it should be performed only at specialized centers in laparoscopic revisional bariatric surgery to ensure an adequate safety profile and a low rate of complications.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
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[31] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861–4. [32] Paluszkiewicz R, Kalinowski P, Wróblewski T, et al. Prospective randomized clinical trial of laparoscopic sleeve gastrectomy versus open Roux-en-Y gastric bypass for the management of patients with morbid obesity. Wideochir Inne Tech Malo Inwazyjne 2012;7:225–32. [33] Trastulli S, Desiderio J, Guarino S, Cirocchi R, Scalercio V, Noya G, et al. Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials. Surg Obes Relat Dis 2013;9:816–29. [34] Diamantis T, Apostolou KG, Alexandrou A, Griniatsos J, Felekouras E, Tsigris C. Review of long-term weight loss results after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10: 177–83. [35] Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis 2009;5:469–75. [36] Goldfeder LB, Ren CJ, Gill JR. Fatal complications of bariatric surgery. Obes Surg 2006;16:1050–6. [37] Moszkowicz D, Arienzo R, Khettab I, Rahmi G, Zinzindohoué F, Berger-Achevallier JM. Sleeve gastrectomy severe complications: is it always a reasonable surgical option? Obes Surg 2013;23:676–8. [38] Hassan EE, Mohamed A, Ibrahim M, Margarita M, Hadad MA, Nimeri AA. Single-stage operative management of laparoscopic sleeve gastrectomy leaks without endoscopic stent placement. Obes Surg 2013;23:722–6. [39] Eisendrath P, Cremer M, Himpens J, Cadière GB, Le Moine O, Devière J. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy 2007;39:625–30. [40] Yehoshua RT, Eidelman LA, Stein M, Fichman S, Mazor A, Chen J, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg 2008;18:1083–8. [41] Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and metaanalysis. Gastrointest Endosc 2012;75:287–93. [42] Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011;21:1520–9.
Original article
Laparoscopic total gastrectomy as an alternative treatment to postsleeve chronic fistula Almino Cardoso Ramos, M.D.a,*, Manoela Galvão Ramos, M.D.a, Josemberg Marins Campos, M.D., Ph.D.b, Manoel dos Passos Galvão Neto, M.D.a, Eduardo Lemos de Souza Bastos, M.D., Ph.D.a a
Gastro Obeso Center, Advanced Institute for Digestive and Bariatric Surgery, Sao Paulo, Brazil b Federal University of Pernambuco, Recife, Brazil Received June 27, 2014; accepted October 26, 2014
Abstract
Background: Sleeve gastrectomy (SG) has become a very common 1-stage procedure in bariatric surgery. Postsleeve chronic fistulas could be one of the possible complications and represent a true challenge for the surgeons. After the failure of more conservative treatments, including surgical and endoscopic approaches, laparoscopic total gastrectomy (LTG) could be an alternative treatment proposal. The objective of this study was to evaluate outcomes of patients who underwent laparoscopic total gastrectomy for the treatment of postsleeve chronic fistula. Methods: Retrospectively review the data from patients after LTG for postsleeve chronic fistula who had failed in all previous treatment attempts with a combination of conservative, endoscopic, and/or surgical approach. Results: From January 2008 to December 2012, 12 patients underwent LTG. Mean time from SG to LTG was 16 months (ranged from 6 to 30). All patients had undergone several previous treatment attempts, including endoscopic techniques (fibrin glue, clips, pneumatic dilation, and stents) and surgical procedures for abscess drainage. Surgical time ranged from 4 to 7 hours with a mean hospital stay of 6 days. Complications occurred in 2 patients (17%) with 1 revision as a result of an intestinal occlusion. There were no conversions to open surgery, anastomotic leaks, or deaths. Conclusions: LTG was feasible in the management of postsleeve chronic fistulas recalcitrant to other treatment approaches with a few complications and high rate of resolution. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Postoperative complications; Anastomotic leak; Gastrectomy
Laparoscopic sleeve gastrectomy (LSG) was initially proposed as part of a combined approach in association with duodenal switch and also as a staged strategy as the first-step surgical procedure for super-obese and high-risk obese patients [1]. Now it has been most commonly accepted as a stand-alone surgical technique becoming more popular all over the world [2–5]. * Correspondence: Almino Cardoso Ramos, M.D., Gastro Obeso Center, Advanced Institute for Digestive and Bariatric Surgery, Rua Barata Ribeiro, 237 Sao Paulo, SP, Brazil. E-mail: [email protected]
Considering the increasing worldwide numbers for LSG in recent years, a higher number of complications can also be expected. The gastric leak and subsequent fistula could possibly be considered the most dreaded complication, with an occurrence of approximately 2% [6–12]. The leak can be present all along the staple-line, but when it happens close to the esophagogastric junction, at the angle of His, the treatment could be a true challenge for the surgeon. Unfortunately, this is the most common site of the leak [13]. A number of therapeutic modalities have been proposed to handle postsleeve fistulas, including surgical or percutaneous drainage [14]; endoscopic therapy with clips, dilation,
http://dx.doi.org/10.1016/j.soard.2014.10.021 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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A. C. Ramos et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
and stents [15–18]; and early resuturing of the leak [19]. When these options fail, surgeons have to resort to more aggressive surgical revisional options, such as converting the sleeve to Roux-en-Y gastric bypass (RYGB) or Roux limb drainage placement at the fistula site [6,20–22]. Laparoscopic partial or total gastrectomy may be the last and most radical options to be offered for selected cases. Total gastrectomy has already been used successfully according to reports of a few cases in the effort to correct the staple-line postsleeve fistula [23–28], but unfortunately, the very small number of patients has not offered enough data to evaluate the safety profile and efficacy of this proposition. The aim of this study is to present a case series of patients who required laparoscopic total gastrectomy (LTG) as treatment for postsleeve chronic fistula after previous failed conservative, endoscopic, or surgical management. Methods The treatment records of patients undergoing LTG for chronic fistula after LSG were reviewed. All consented and signed a form allowing medical records to be reviewed and published with previous approval of the local review board. Preoperative upper endoscopy, computed tomographic (CT) scan, and gastrointestinal radiographic series were performed to evaluate the site and path of the fistula and possible stricture or other sleeve-associated anatomic abnormalities. Total parenteral nutrition or enteral feeding were indicated in every case to improve nutritional status for the procedure. Previous treatment sessions of endoscopic management involving clips, fibrin glue, high-pressure pneumatic balloon dilation, and coated self-expanding stent placements and operations to drain abscesses and improve septic conditions were performed in all patients before the gastrectomy by interventional radiology, endoscopy, and laparoscopic approaches. Only after the failure of all of these was the LTG performed as a surgical attempt to resolve the clinical situation by removing the chronic fibrotic and damaged tissue, relocating the staple line, and performing an anastomosis in healthy tissue, looking for better chance of healing. Surgical technique LTG was undertaken in the split-leg position with the operating surgeon standing between the patient’s legs. Pneumoperitoneum was created with an optical bladeless trocar and 4 more surgical ports were inserted, using the previous incisional sites when possible. The lesser curvature and anterior wall of the remnant-sleeved stomach were, in general, severely adhered to the left lobe of the liver and abdominal wall, and careful removal of adhesions was done with hook electrocauterization, regular scissors, and harmonic shears. Dissection of the gastric sleeve greater curvature, lesser sac, hiatus, and esophagus was performed, and the vessels of the stomach were identified, divided, and clipped. The first
portion of duodenum was dissected and then stapletransected 2 cm below the pylorus using a linear stapler device with a 45-mm white cartridge. After full mobilization of the abdominal esophagus, it was transected with a 45-mm blue cartridge linear stapler. The biliopancreatic limb was measured from the ligament of Treitz for 50–60 cm; the intestinal limb was anastomosed to the esophagus (E-J anastomosis) with a 45-mm blue cartridge linear stapler and sutured over a 32F bougie with polydioxonone 3-0 (PDS®, Ethicon Endo Surgery, Inc.) 3-0 extramucosal running suture with no calibration. A side-to-side jejunojejunostomy was constructed with the alimentary limb at 100 cm with a 45-mm white cartridge linear stapler and closed with an extramucosal 3-0 PDS running suture. The Petersen and mesenteric openings were closed with nonabsorbable, running Ethibond 2-0 suture, and a methylene blue leak test was done. Then the Billroth II like limb was converted into a Roux-en-Y by dividing the limb connecting the E-J and enteroanastomosis with a 45-mm white cartridge linear stapler. A drainage tube was placed around the E-J anastomosis and the duodenal stump; fascial incisions 410 mm and the skin incisions were closed. All the operations were done in a high-volume bariatric center by the same bariatric surgeon, who performed approximately 1000 bariatric procedures each year. Results Over a period of 5 years (from January 2008 to December 2012), the charts of 12 patients (n = 12; 5 male patients) with a mean age of 44.5 years (range 18–62) undergoing LTG for esophagogastric junction chronic fistula after LSG were included. All but 1 patient were referred cases. The average total operative time of these procedures was 5 hours (range 4–7). The previous number of surgical interventions before the total gastrectomy ranged from 1 to 6 (mean 4) per case. Also patients were submitted to endoscopic attempts to close the fistula with an average of 5 sessions (range 3–8). Time from LSG to LTG ranged from 6 to 30 months (mean 16 mo). Patients had a postoperative length of stay of 6 days (range 5–12) and were able to walk on the second postoperative day. A liquid diet was given to most of them on the third postoperative day. There were no deaths, and complications occurred in 2 cases, with pneumonia in 1, treated with antibiotics and pulmonary physiotherapy, and an intestinal occlusion in another, caused by partial bowel herniation at the site of 1 of the 12-mm trocars (Richter hernia). This last patient required reoperation on the fifth postoperative day with good recovery. Demographic data and other clinical features of the patients are summarized in Table 1. Discussion The sleeve gastrectomy (SG) was first described as an effort to improve the results of the classic biliopancreatic
Laparoscopic Total Gastrectomy / Surgery for Obesity and Related Diseases ] (2015) 00–00 Table 1 Demographic data and clinical features from all 12 patients undergoing LTG for chronic fistula after sleeve Patient Age Gender Previous Time Sessions of Operative Length (yr) surgery from endoscopy time (hr) of stay LSG therapy* to LTG (mo) 1 62 2 54 3 48 4 35 5 42 6 18 7 59 8 50 9 32 10 47 11 37 12 52 Mean 44.5
M M M F F F F M F M F F
6 5 3 1 2 5 1 2 6 4 5 6 4
18 12 14 11 13 18 7 6 30 20 24 22 16
8 3 6 6 5 8 5 4 4 5 4 6 5
7 4.5 5 6.5 5. 5.5 4 6 5.5 5 4 5 5
12 5 6 5 7 10 6 5 7 6 5 6 6
Abbreviations: LSG ¼ laparoscopic sleeve gastrectomy; LTG ¼ laparoscopic total gastrectomy; M ¼ male; F ¼ female.
diversion (BPD) [29] and some years later was reported by laparoscopy [30], as a part of the BPD as well. At first, LSG was mainly performed as a first-stage in high-risk morbidly obese patients [31], but more recently, based on the good results published as a bariatric or metabolic procedure, it has gained popularity as a stand-alone surgery [32–34]. Currently, LSG is recognized both as a primary bariatric procedure and as a first-step practice in high-risk patients as part of a planned staged surgical strategy [4]. Reflecting this fast acceptation and growing number of LSG procedures, an increasing rate of complications would also be expected, especially because the LSG has some potential technical pitfalls and a lot of surgeons who perform it are still novices in bariatric surgery, within the “LSG learning curve.” LSG complications have been reported in almost one quarter of the procedures [35]. Postsleeve gastric leaks are the most dreaded complication and very often can be the source of major morbidity, long length of stay, high costs, and mortality risk. Leaks occur when the gastric contents pass through the staple line because of its insufficient closure or rupture. Studies are not conclusive about the reasons for leak, but it seems that the high pressure inside the gastric tube and healing problems in the angle of His area are the most important related factors. When these leaks become chronic, producing an epithelialized path, a fistula is formed, which may not close spontaneously and may become refractory to the conventional clinical treatment. In general, these cases demand more time to resolve and require treatment with specialized endoscopic and radiologic approaches or even complex surgical revisions. In this situation, the patient is often required to be referred to a center of excellence in bariatric
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surgery for skilled therapy because these fistulas are associated with a significant risk of death [36]. The most recent position statement of the American Society for Metabolic and Bariatric Surgery (ASMBS) corroborates this concern about postsleeve staple line leaks and reports an occurrence in 1%–3% of patients in large published series [4]. It may be true that most of the leaks are very low volume, transient, asymptomatic, and close spontaneously. Therefore, the actual incidence of the leak may be greater than reported. On the other hand, some leaks may require a wide range of therapeutic modalities, especially those that occur close to the esophagogastric junction. The first step in postsleeve leak management is a quick and correct diagnosis. All suspected or diagnosed patients should receive the same initial care, with fluid replacement, nutritional support, antibiotics, and appropriate targeting of the leakage abscess. Radiologic percutaneous or laparoscopic drainage are generally the best initial options. Surgical closure by resuturing the hole of the leak may also be tried but usually fails [37], especially in late leaks [19]. The setting of appropriate surgical drainage with very aggressive nutritional support may lead to the leak healing in some cases [38], and this option is especially valuable in hospitals without expertise in bariatric surgery. After clinical stabilization, the available therapies can range from a simple clinical observation for spontaneous healing, endoscopic assessment, and surgical drainage to more radical surgery options such as total gastrectomy. In regard to endoscopic therapy, including an emerging list of less invasive alternatives to surgery, very fashionable currently, it is very important to notice that postsleeve fistulas are usually the most difficult to heal in comparison with RYGB [39], maybe because of the higher pressure within the stomach in sleeve [40]. The true effectiveness of endoluminal therapy in postsleeve fistula may not have been totally proven because the studies are based only on case series, with few numbers, including a very heterogeneous group of patients, and do not usually report important details with no possibility of randomization. In the authors’ opinion, however, endoscopy should always be attempted before radical surgery treatment, because successful leak closure with pneumatic dilation and the use of selfexpandable stents is almost 90% [41]. For this reason, in the present series, all the patients undergoing LTG first had endoscopic treatment, with sessions ranging from 3 to 8 (mean 5), including the use of fibrin glue, clips, balloon pneumatic dilation, and double-coated metallic stents. In attempt to increase the success rate of drainage and endoscopic management, it is important to ensure the absence of sleeve-associated strictures or rotation [42]. The current available options for the radical surgical treatment of the postsleeve chronic fistula include a Roux limb placement at the site of the leak, conversion from SG to RYGB, and partial or total gastrectomy [27]. In the present series, the LTG was chosen. Even if this operation could be
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considered technically complex, it may represent the patient´s last possibility for cure. The authors believe that it should only be done at centers with extensive experience in laparoscopic revisional surgery. The use of Roux limb placement can be undertaken as early as 4 weeks after the leak has been diagnosed in the effort to save costs [21,22]. Beyond the great technical difficulty in performing the anastomosis between the leak area with very thick, fibrous, and inflamed tissue and the jejunal limb, this operation usually promotes a double alimentary route and the longterm clinical outcomes are uncertain. It seems logical to assume this will compromise the intended restrictive effect of the SG affecting the final weight loss. Conversion to RYGB could also be a successful strategy based on the fact that gastric bypass leaks tend to have better outcomes than those after SG, probably as a result of relief of pressure in the sleeve. However, this may be associated with complications in the new staple line and gastrointestinal anastomosis, and the risk of not achieving closure of the leak in the stomach pouch should be considered. Also, the final weight loss could not be predictable. Although postoperative leaks after total gastrectomy have been reported [27], based on the reports of successful total gastrectomy to treat chronic postsleeve fistula (associated with duodenal switch or not) [23–28], it was decided to perform LTG as the last surgical option. In the present series, there was no mortality and no major technical complications related to this supposed high-risk esophagojejunal anastomosis. All of our patients underwent total gastrectomy with laparoscopic approach. Although a laparotomic approach might seem to be less difficult with the dense adhesions from the prior surgery, the laparoscopic approach, even more laborious, can benefit patients when performed by trained surgeons with faster and more comfortable recovery. To the best of the authors’ knowledge, this has been the largest LTG case series published so far. The most important advantage of this technique is to work with healthy tissue with no inflammation or fibrosis, because the diseased sleeved stomach and the fistula tract will be removed. The anastomosis can be done between the normal esophagus and jejunum with much more predictable results. The main limitation to support the conclusions may be the type of study performed: a retrospective case series. To compare with other surgical options, a randomized, multicenter study is required, but this is almost impractical. Because of the unpredictability of the occurrence of cases, this type of trial would require a long study period to enroll an adequate number of patients. Conclusions LTG is a feasible and effective treatment option for refractory postsleeve chronic fistula, but it should be performed only at specialized centers in laparoscopic revisional bariatric surgery to ensure an adequate safety profile and a low rate of complications.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
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