Managing ComplicationsFIRST Prevent Complications Better to Prevent a Leak than to be Expert in Managing a Leak

1. Managing Complications
FIRST
Prevent Complications

2. Safety & Bariatric Surgery
Complacency
• When surgeons Don’t
rigorously adhere to pre-op
rules or checklist in selecting
& preparing their patient, their
team & themselves

3. Examples of Complacency
Sleeve Gastrectomy Failure:
• “Sleeve Gastrectomy & Risk of Leak:
Systematic Analysis of 4,888 Patients”
• “Risk of leak is low at 2.4%"
•
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011
Dec 17. Aurora AR, Khaitan L, Saber AA. Department
of Surgery, University Hospitals Case Medical Center,
Cleveland, Ohio

4. “Risk of leak is low at 2.4%"
Air India Airlines
Releases the following statement:
“Risk of Airplane Crashes are Low at only 2.4%"

5. The Mindset of
Commitment to Excellence
Make the Commitment
To your Patient:
“Failure is Not an Option”
NO LEAKS

6. Don’t Manage a Complication?
Prevent, Prevent, Prevent

7. Complication Management
vs.
Complication Prevention
Better to
Prevent a Leak than to be
Expert in
Managing a Leak

8. First:
Leaks Much More Likely in
First 100 Cases

9. Volume Performance
New Surgeons = More Complications

10. Complications Decrease
with Experience

11. New Surgeons are
Dangerous & Deadly Surgeons
Complications decline to
logarithm of the surgeons’
Training & Experience

12. First: Leaks Much More Likely in
First 100 Cases
What are the implications?
In the first 100 cases
NO Difficult Cases
Get Help
Eplore Early and Often
Fear a Leak in Everyone

13. RNY: Long learning curve of
500 cases
RNY technically challenging 2,281 cases 1999 2011
Complications diminished with
increased experience
Stabilized <2.5% after the first 500 cases
Mortality rate .43%,
main causes of death PE & Leaks (.14% each)
Op time & Complications significantly reduced
after a long learning curve of 500 cases
Surg Obes Relat Dis. 2013 Feb 11. Overcoming the learning curve of laparoscopic Roux-en-Y gastric bypass: A 12year experience. El-Kadre L, Tinoco AC, Tinoco RC, Aguiar L, Santos T. Department of Surgery, São José do
Avaí Hospital, Itaperuna, Rio de Janeiro, Brazil.

14. What can we learn from the
Airline Industry
Failure is Not an Option

15. Laparoscopic sleeve gastrectomy for failed
laparoscopic adjustable gastric band
800 pts LSG
5.5 % leak & 4.4 % hemorrhage
Conclusions: “We advocate this
procedure as
a good bariatric option (?)
No No No!
Obes Surg. 2013 Mar;23(3):300-5. Laparoscopic sleeve gastrectomy (LSG)-a good bariatric option for failed
laparoscopic adjustable gastric banding (LAGB): a review of 90 patients. Yazbek T, Safa N, Denis R, Atlas
H, Garneau PY. Hôpital du Sacré-Coeur de Montréal, 5400 boul. Gouin ouest, Montreal, Quebec, Canada

16. RNY/MGB Post Op Complications
Complication
Bleeding
Leak
Wound infection (requiring hospital
treatment)
Intestinal obstruction
Intra-abdominal abscess
Pulmonary thromboembolism
Total of early complications
RNY% MGB%
2.6
0.2%
2.4 0.2%
2.2
1.1
0.7
0.6
9.6
0.1%
0.0%
0.1%
0.2%
0.8%

17. Controlled Prospective Randomized Trial
Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus MiniGastric Bypass for the treatment of Morbid Obesity. Ann Surg 2005 ; 242 : 20-28
RYG Bypass
Mini Bypass
Op time (mns)
205
148
Early complications
20%
7.5%
Late complications
7.5%
7.5 %
EWL at one year
58.7%
64.9%
EWL at two years
60%
64.4%

18. SECO 2012
BARCELONA SPAIN
Laparoscopic Mini Gastric Bypass
Cesare Peraglie MD FACS FASCRS
CLOS-Florida: Heart of Florida Regional Medical Center.
Davenport, Florida
drperaglie@gmail.com

19. Laparoscopic-Mini Gastric Bypass: HOFRMC
•Over 1000 Laparoscopic MGB’s have been performed at HOFRMC since 2005.
•TYPICAL DEMOGRAPHICS: AGE: 45 (14-72), BMI: 45 (30-75), ~27% DIABETIC, ~50% HTN,
~31% PREVIOUS ABDOMINAL SURGERY
•OUTCOMES
 OP-TIME: 62Min. (37-186), Conversion to open: 0
 LOS: 1 DAY or less (88%), 2 DAY (10%), 3 DAY (~2%), 4+
DAY (<1%)
 Re-admission: 5% (23 hour obs. PONV in all but one) /
0.8% 90 day
 Leak: 0.3%
 MORTALITY: 0 (HOSPITAL), 0 (PERI-OP:90D)

20. Stapled vs Handsewn Anastomosis
Linear Stapled vs Handsewn EsophagoGastrostomy
Anastomotic leak:
1 (3.0%) of 33 stapled
13 (14.4%) of the 90 Hand Sewn
(P = 0.07)
Surg Today. 2009;39(3):201-6. The triangulating stapling technique for cervical esophagogastric anastomosis after
esophagectomy Toh Y, Sakaguchi Y, Ikeda O, Adachi E, Ohgaki K, Yamashita Y, Oki E, Minami K, Okamura
T.Department of Gastroenterological Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku,
Fukuoka, 811-1395, Japan

21. NSAIDs should be abandoned in GI
anastomoses
Anastomotic leak (AL) is the most important &
one of the most serious complications after
GI anastomosis
Factors that contribute to increase the risk of
AL should be identified and--if possible-eliminated
Prostaglandins promote neo-angiogenesis &
enhanced wound healing
Non-steroidal anti-inflammatory drugs
(NSAIDs) are often used for treating pain
after surgical procedures

22. NSAIDs be abandoned after
primary GI anastomosis
Retrospective, case-control study in 75 patients
undergoing laparoscopic colorectal resection
for colorectal cancer.
33 of these patients received the NSAID
diclofenac in the postoperative period
42 did not receive any NSAID.
There were significantly more LEAKS among
the patients receiving diclofenac
(7/33 vs. 1/42, p=0.018)

23. NSAIDs should be abandoned after
primary GI anastomosis
Database study based on data from the Danish
Colorectal Cancer Group's (DCCG) prospective
database & electronically registered medical records.
From the database information on demographic, surgical
& postoperative variables (including AL) were
provided.
Information on NSAID consumption was retrieved by
individual searches in the patients' medical records.
Based on these data, uni- & multivariate logistic
regression analyses were performed.
These analyses identified NSAID treatment in the
postoperative period as an individual risk factor for
Leak

24. MGB/RNY/SG Complications
Short term:
Leak
Bleeding
Venous thrombosis
Infections, Pneumonia
SBO from abdominal hernia
Anastomotic stricture
Technical Errors
Arq Gastroenterol. 2013 JaSanto MA, Pajecki D, Riccioppo D, Cleva R, Kawamoto F, Cecconello I.Metabolic & Bariatric Surgery Unit, Discipline
of Digestive Surgery, University of São Paulo Medical School (Unidade de Cirurgia Bariátrica e Metabólica, Disciplina de Cirurgia do
Aparelho Digestivo. Faculdade de Medicina da Universidade de São Paulo), São Paulo, SP, Brazil. santomarco@uol.com.br

25. Leak Prevention
Leak Location Site:
1. EG Junction (Think Sleeve)
Prevention: Simple:
AVIOD e.g. Junction!
2. Gastro Jejunostomy
Prevention: Technical Details of
Laparoscopic GI anastomosis
(Remember the
Basics of General Surgery)

26. Learning from Sleeve Leak Experience
Division of the posterior fundic vessels is also
performed.
(NO NO NO)
“The angle of His is then dissected free from the left
crus of the diaphragm.”
(NO NO NO)
Careful attention on dissection must be taken due to
the risk of splenic or esophageal injury
Prevention:
Simple:
AVIOD the EG Junction!

27. Learning from Sleeve Leak Experience
In 33 of the patients
(75-95%), the leaks
near the
gastroesophageal
junction
Prevention:
Simple:
FEAR the
EG Junction!

28. Anastomotic Leak Prevention
ALWAYS DO A SAFE
ANASTOMOSIS
Preop Factors
Intra-op Factors
Post Op Factors

29. Leak Prevention
ALWAYS DO A SAFE
ANASTOMOSIS
No Leak.
Cause no persistent bleeding.
Cause no stricture of the lumen.
Create no risk for internal hernia.

30. Patient Factors Affect GI
Anastomitic Healing
Look for these factors:
Correct these factors or REJECT the Patient
1. Renal/Cardiac/Pulmonary Dysfunction
2. Bacterial contamination
3. Inflammation
4. Shock & hypoperfusion states
5. Diabetes mellitus
6. Chronic steroid use
7. Poor nutritional status
8. Malignancy

31. PREOP Fundamentals of GastroIntestinal Anastomosis Healing
NO NSAIDs, Steroids, Anti-Metabolites (fluorouracil
decreased anastomotic breaking strength by more
than 40%)
Accurate Fluid Administration
STOP Smoking
Adequate Vitamin A levels
Aggressive Control of Glucose Levels
Early feeding liquid protein & calories
Preop Statins
Preop Creatine Supplements
Preop Exercise (Increase Testosterone, HGH)
Supplemental Oxygen in All patients

32. Fundamentals of Gastro-Intestinal
Anastomosis Healing
Adequate local blood supply (Carefully maintain
mesentery)
Elimination of tension (Long Pouch,left gutter for
bowel. Do Not Divide the Omentum)
Meticulous Hemostasis (avoid damage to staple
line)
Gentle & precise handling of tissues
Closure of mesenteric defects (Not in MGB)
Close inspection
Accurate Suture Placement (NOT Many Sutures,
3 layers are not better than 1-2)

33. Fundamentals of Gastro-Intestinal
Anastomosis Healing
Adequate local blood
supply
Maintain mesentery
Elimination of tension
Long Pouch
Left gutter for bowel

34. Fundamentals of Gastro-Intestinal
Anastomosis Healing
Meticulous
Hemostasis
SLOW Staple Gun
Firing
Avoid damage to
staple line
Do Not Touch the
Staple Line
Gentle & precise
handling of tissues

35. Fundamentals of Gastro-Intestinal
Anastomosis Healing
Inverted vs. Everted
1800s, Lembert, Halsted
advocated an inverted,
serosa-to-serosa anastomosis
Hand-sutured everting bowel
anastomosis point out
Simplicity & decreased risk of
bowel lumen narrowing
Animal experiments in the 1960s
& 1970s demonstrated no
difference in healing strength
& leak rates between the two
approaches

36. Fundamentals of Gastro-Intestinal
Anastomosis Healing
Approximately 3-mm gap
between two sutures
Care not to apply
excessive tension to
prevent cut-through of
seromuscular layer
It is necessary to include
submucosa carefully
because it is the
strongest layer of the
bowel wall and gives
strength to anastomosis.

37. Handle tissue gently & precisely
“approximate, do not strangulate” to avoid
ischemia of the bowel wall at the
anastomosis.
For stapled anastomoses, use the correct
staple height for the tissue thickness.
Too short & ischemia;
Too long, & bleeding or leak
The common staple height for the small bowel
& colon is 3.5 blue, 3.5 mm
For the thicker stomach, green, 4.8 mm

38. Fundamentals of Gastro-Intestinal
Anastomosis Healing
1 Layer, Maybe 2, Not More (Ischemia)
Remember your general surgery
Inverted => Narrowing of the Lumen & early
complaints of Nausea & Vomiting Patient
complaints, stress on the anastomosis &
prolonged hospitalization
Stapled vs Handsewn
Buttress/Fibrin Glue/Omental Patch?

39. Meta-analysis of randomized controlled
trials single- vs two- layer intestinal
anastomosis
Six trials were analyzed, comprising 670
participants (single-layer group, n = 299; twolayer group, n = 371).
Data on leaks were available from all included
studies.
Combined risk ratio 0.91 (95% CI = 0.49 to
1.69), & indicated no significant difference.
Single- versus two- layer intestinal anastomosis: a meta-analysis of randomized controlled trials Satoru Shikata1,2†,
Hisakazu Yamagishi1†, Yoshinori Taji2†, Toshihiko Shimada3† & Yoshinori Noguchi3 BMC Surgery 2006, 6:2
doi:10.1186/1471-2482-6-2

40. Note:
NO ONE Recommends 3 or 4
Layer Anastomosis
No Staple Company
Recommends Oversewing the
Staple Line

41. Prevent Bleeding:
“Go Slow
to
Go Fast”
Case Mantra:
“No Bleeding”
“Easy Case”

42. How to Stop Bleeding:
Direct Pressure - First Aid
Use the Stapler to
Compress the
staple line
wound
How to Stop
Bleeding
Direct Pressure
First Aid

43. Stapler Use
Warnings
Ensure to select a stapler with the appropriate staple size for the
tissue thickness. Overly thick or thin tissue may result in
unacceptable staple formation.
Do not attempt to remove the shipping wedge until the stapler is
loaded into the instrument.
Do not squeeze the handle while pulling back the black retraction
knobs.
Do not attempt to override the safety interlock; to do so will render
the stapler nonoperational.
Failure to completely fire the stapler will result in an incomplete cut
and incomplete staple formation, and may until in poor
hemostasis.

44. Management Leaks
Simple:
In ANY Post Op Patient with ANY
Complaints
Do: Rexplore
Do Not: WBC, CXR or other Plain Film
Do Not: CT Scan or Gastrograffin
Swallow
The Only Answer Rexplore

45. Management Post Op Leaks
1. First Prevent Leaks
2. Categorize:
Early Leaks vs Late Leaks
3. Second Simple Management
Protocol

46. Leak Management
Leak found 24-48hr
= No Diagnostic Tests
= Immediate Exploration
= Usually Simple Suture Repair
Leak Found More than 72 hours
= Take down GJ (1 Staple Firing) 5-10 min
= Gastro-Gastrostomy (5-10 min)
= Get Out (Drain and ABx)

47. Leak Management
Fear Leak: Suspect a Leak in Every Case
Leak found 24-48hr
= No Diagnostic Tests
No WBC
No CAT Scan
No Chest XRay
If patient does not feel well reexplore early
= Immediate Exploration
Expect many negative explorations when you begin
= Usually Simple Suture Repair

48. Abdominal Abscess Minimal Sx
Drain Percutaneous and Antibiotics