Endolumenal strategies on RYGB leaks
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Transcript of Endolumenal strategies on RYGB leaks
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LEAKS IN RYGB
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JOSEMBERG CAMPOS, PHDMANOEL GALVAO NETO, MDALMINO C. RAMOS, MD
Recife, PE, Brazil
Sao Paulo, SP, Brazil
Sao Paulo, SP, Brazil
Recife, PE, Brazil
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ALMINO CARDOSO RAMOS MANOELA GALVÃO MANOEL GALVÃO NETO ANDREY CARLO
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RYGB LEAKSENDOSCOPIC APPROACH
• Learning objectives
• Define RYGB leak
• Unveils the RYGB endoscopic anatomy
• Understand the place of endoscopy on RYGB leaks
• Recognize the possible endoscopic treatments
• Identify the role of stents and its principles on RYGB leaks
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• Fistula • abnormal communication originating in a visceral
structure.• Leak
• one type of fistula, is defined as discontinuity of tissue apposition in the immediate postoperative period.
• The incidence of RYGB leak • 1.7%–2.6% after open RYGB• 2.1%–5.2% after laparoscopic
Morales MP, Miedema BW, Scott JS, et al. Management of postsurgical leaks in the bariatric patient. Gastrointest Endosc Clin N Am 2011;21:295–304.
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• Leaks develop when intraluminal pressure exceeds tissue or suture line resistance.
• Leaks presenting within the first 2 days postoperatively are often mechanical
• Leaks presenting within 5–6 days tends to be ischemic leaks
• Risk of leak • impaired healing / infection / diabetes / hypertension /
sleep apnea / age >55 years / male gender and prior surgery.
Fernandez AZ, DeMaria EJ, Tichansky DS, et al. Experience with over 3000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc 2004;18:193–197.Ballesta C, Berindoague R, Cabrera M, et al. Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008;18:623–630.Livingston EH, Huerta S, Arthur D, et al. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg 2002;236: 576–582.
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RYGB Leaks can lead to mortality
of 6%–14.7%.
Lee S, Carmody B, Wolfe L, et al. Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases. J Gastrointest Surg 2007;11:708–713.
Carucci LR, Turner MA, Conklin RC, et al. Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of postoperative extraluminal leaks with upper gastrointestinal series.Radiology 2006;238:119–127.
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Leaks / Fistulas
RNY Gastric Bypass leaks
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GASTRO-ENTERO“POUCH” GASTRO-ENTERO
RNY Gastric Bypass leaks
Gastro-Cutaneous fistula
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Gastro-gastric fistula
RNY Gastric Bypass leaks
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RNY Gastric Bypass leaks
Gastro-Bronqueal fistula
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First control the sepsis
Laparoscopy
Percutaneous
Laparotomy
Stabilize the patient
RNY Gastric Bypass leaks
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RNY Gastric Bypass leaks
Most of them heals up to 30d
Clinical management usually works
Drain / Gastrostomy / NET…
Traditional therapeutic endoscopy
Always dilate first
Don’t waist on clips, glue, mesh…
Stent if it fails….
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RNY Gastric Bypass leaks
Endoscopic treatment
Dilation– correct the flow…
RYGB GJ are built to be “stenotic”
< 20mm
So dilate to 20mm first
Measure the results in terms of
Leak flow Patient general status improvement
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Endoscopic balloon dilation
RNY Gastric Bypass leaksDilate first
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RYGB Leaks Stents
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RNY Gastric Bypass leaks
Endoscopic treatment
Stents
Actual models were design for
malignancies
They don’t fit all the design
needs for bariatric surgery
leaks
New models are coming
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Bariatric upper leaksPlastic- Silicon
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Implant…
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Removal…
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Bariatric upper leaksMetallic single covered- Nitinol
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Bariatric upper leaksProsthesis – New modelsNitinol double covered…
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Type
N F/M Bypass Sleeve Prosthesis on siteDays
Fistula clousure
Poliflex®
Silicone
15 10F / 5M
13p 2p 45d
(21 – 91d)
14p
93%
Hanaro/Choo®
Nitinol
12 8F / 4M 10p 2p 41d
(25 – 86d)
11p
91,6%
EndoBarrier®
Nitinol / Teflon
2 2F -- 2p 48d
(40 and 56d)
2p
100%
29pBariatric upper leaksStents – Casuistic up to 2008
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Type
Dislodgment SignificantReflux
Surgical removal
Poliflex®
Silicone
8p
53,3%
6p
40%
1pDislodgement
7%
Hanaro/Choo®
Nitinol
2p
16,6%
4p
33,3%
1pNot able to
remove8%
EndoBarrier®
Nitinol / Teflon
1p None None
29pBariatric upper leaksStents – Casuistic up to 2008
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RYGB Leaks Complementary procedures
Septomy
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Septomy
CAUTERY + PNEUMATIC DILATIONRESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)
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Septomy
CAUTERY + PNEUMATIC DILATIONRESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)
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RYGB Leaks Endoscopic treatment can be used even on the worst
scenarios
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Fístula Gastrobronchial
Obes Surg, 2011
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Sleeve Gastrectomy - Complications