OBES SURG DOI 10.1007/s11695-015-1698-3
LETTER TO THE EDITOR
Pigtails Internal Drainage for 2-cm Gastric Leak After Sleeve Gastrectomy Prolongs Healing Thierry Manos 1 & Marius Nedelcu 2 & Patrick Noel 3 & Michel Gagner 4
# Springer Science+Business Media New York 2015
We would like to thank Donatelli et al. for the opportunity to comment on his complicated case report of a leak after laparoscopic sleeve gastrectomy (LSG) with a 2-cm-long dehiscence. We would like to make some remarks. In the selected case presented, a dehiscence of 2 cm is unusual and the technique used for the initial laparoscopic sleeve gastrectomy (LSG) must be questionable. A description of the initial procedure is suitable, describing the technique of dissection, the bougie size, the type of stapling, and the reinforcement used. Such a large defect can be explained by necrosis which occurred after dissection, by mischoice of stapling device, or/and poor choice of reinforcement type. The gastric leak healed by pigtails approach (although some may re-opened at a later date), but no details about the presence of gastric stenosis was mentioned. A twisted, poorly constructed sleeve will add insult to the injury and it necessitates the deployment of an endoscopic stent. Still the patient needed seven endoscopic sessions and 206 days to close the leak. In our proposed algorithm [1], for patients with gastric stenosis treated with tailored approach and endoscopic stent, the leaks achieved complete healing after an average duration of 118 days (a 75 % reduction in time). This difference of the healing time is increasing cost and patients’ sufferance unnecessarily.
The occurrence of a gastropleural fistula could also be explained by the presence of a concomitant hiatal hernia misrecognized during the initial procedure. If this was the case, it should have been operated contemporaneously and the gastropleural fistula could have been avoided. The OVESCO® clip (OTSC®; Ovesco Endoscopy GmbH, Tübingen, Germany) in this setting was, in fact, contraindicated. The authors Bbelieve^ that in their experience, the stents will increase the local ischemia and subsequently increase leak in size. We do not agree with the statement that stents cause ischemia, as no recent data in the literature [2, 3] supports it. The debate on the algorithm regarding the leak size when no stenosis is associated will remain open. Most centers are proposing, for all types of leaks after LSG, an endoscopic stent [4, 5]. The main purpose of the algorithm with our early experience of 19 cases was to change this dogma and to offer patients with this dreaded complication after LSG, a tailored approach. We remain unconvinced that pigtail drains represent a solution for all the types of leak, irrespective of leak size, and we are waiting for a new updated manuscript with all 200 cases from the authors.
References * Marius Nedelcu [email protected]; [email protected] 1
Bouchard Clinic, Marseille, France
2
Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1, Place de l’Hôpital, 67091 Strasbourg, France
3
Private Hospital La Casamance, Aubagne, France
4
Sacre Cœur Hospital, Montreal, QC, Canada
1.
2.
3.
Nedelcu M, Manus T, Cotirlet A et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. Obes Surg. 2015;25(3):559–63. doi:10.1007/s11695014-1561-y Shim CN, Kim HI, Hyung WJ, et al. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc. 2014;28(3):833–40. Alazmi W, Al-Sabah S, Ali DA, et al. Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature. Surg Endosc. 2014;28(12):3425–8.
OBES SURG 4.
Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008;206(5):935–8. discussion 938–9.
5.
Simon F, Siciliano I, Gillet A, et al. Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time. Obes Surg. 2013;23(5):687–92.
LETTER TO THE EDITOR
Pigtails Internal Drainage for 2-cm Gastric Leak After Sleeve Gastrectomy Prolongs Healing Thierry Manos 1 & Marius Nedelcu 2 & Patrick Noel 3 & Michel Gagner 4
# Springer Science+Business Media New York 2015
We would like to thank Donatelli et al. for the opportunity to comment on his complicated case report of a leak after laparoscopic sleeve gastrectomy (LSG) with a 2-cm-long dehiscence. We would like to make some remarks. In the selected case presented, a dehiscence of 2 cm is unusual and the technique used for the initial laparoscopic sleeve gastrectomy (LSG) must be questionable. A description of the initial procedure is suitable, describing the technique of dissection, the bougie size, the type of stapling, and the reinforcement used. Such a large defect can be explained by necrosis which occurred after dissection, by mischoice of stapling device, or/and poor choice of reinforcement type. The gastric leak healed by pigtails approach (although some may re-opened at a later date), but no details about the presence of gastric stenosis was mentioned. A twisted, poorly constructed sleeve will add insult to the injury and it necessitates the deployment of an endoscopic stent. Still the patient needed seven endoscopic sessions and 206 days to close the leak. In our proposed algorithm [1], for patients with gastric stenosis treated with tailored approach and endoscopic stent, the leaks achieved complete healing after an average duration of 118 days (a 75 % reduction in time). This difference of the healing time is increasing cost and patients’ sufferance unnecessarily.
The occurrence of a gastropleural fistula could also be explained by the presence of a concomitant hiatal hernia misrecognized during the initial procedure. If this was the case, it should have been operated contemporaneously and the gastropleural fistula could have been avoided. The OVESCO® clip (OTSC®; Ovesco Endoscopy GmbH, Tübingen, Germany) in this setting was, in fact, contraindicated. The authors Bbelieve^ that in their experience, the stents will increase the local ischemia and subsequently increase leak in size. We do not agree with the statement that stents cause ischemia, as no recent data in the literature [2, 3] supports it. The debate on the algorithm regarding the leak size when no stenosis is associated will remain open. Most centers are proposing, for all types of leaks after LSG, an endoscopic stent [4, 5]. The main purpose of the algorithm with our early experience of 19 cases was to change this dogma and to offer patients with this dreaded complication after LSG, a tailored approach. We remain unconvinced that pigtail drains represent a solution for all the types of leak, irrespective of leak size, and we are waiting for a new updated manuscript with all 200 cases from the authors.
References * Marius Nedelcu [email protected]; [email protected] 1
Bouchard Clinic, Marseille, France
2
Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1, Place de l’Hôpital, 67091 Strasbourg, France
3
Private Hospital La Casamance, Aubagne, France
4
Sacre Cœur Hospital, Montreal, QC, Canada
1.
2.
3.
Nedelcu M, Manus T, Cotirlet A et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. Obes Surg. 2015;25(3):559–63. doi:10.1007/s11695014-1561-y Shim CN, Kim HI, Hyung WJ, et al. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc. 2014;28(3):833–40. Alazmi W, Al-Sabah S, Ali DA, et al. Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature. Surg Endosc. 2014;28(12):3425–8.
OBES SURG 4.
Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008;206(5):935–8. discussion 938–9.
5.
Simon F, Siciliano I, Gillet A, et al. Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time. Obes Surg. 2013;23(5):687–92.
