PREVENTIONandTreatment of Sleeve Gastrectomy Leaks Dr Rutledge Where does it occur? ONE PLACE! This is “Tiger Country” – remember that! Managing ComplicationsFIRST Prevent Complications Managing LeaksFirst Prevent Leaks!! Examples of ComplacencySleeve Gastrectomy Leak “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

1. PREVENTION
and
Treatment of
Sleeve Gastrectomy Leaks
Dr Rutledge

2. Sleeve Leak
• Where does it
occur?
• ONE PLACE!

3. Sleeve Leak
• Where does it
occur?
• ONE PLACE!
• This is “Tiger
Country” –
remember that!

4. Sleeve Leak

5. Sleeve Leak
• Where does it
occur?
• ONE PLACE!
• This is “Tiger
Country” –
remember that!

6. Sleeve Leak
A Tragedy of Unimaginable Proportions
• Sleeve gastrectomy
severe
complications: is it
always a reasonable
surgical option?
•
•
Moszkowicz D, Chevallier JM.
Assistance Publique-Hôpitaux de Paris,
University Paris 5, Paris, France.
•
Obes Surg. 2013 May;23(5):676-86.

7. Sleeve Leak
Sleeve gastrectomy severe complications
• Twenty-two consecutive patients were
referred between January 2004 and
February 2012 with postoperative gastric
leak or stenosis after LSG.
• 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.

8. Sleeve Leak
Sleeve gastrectomy severe complications
• Twenty-two consecutive patients were referred
between January 2004 and February 2012 with
postoperative gastric leak or stenosis after LSG.
• 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).

9. Sleeve Leak
Sleeve gastrectomy severe complications
• 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.

10. Managing Complications
FIRST
Prevent Complications

11. Managing Leaks
First
Prevent Leaks!!

12. Error in Thinking of
Complications in Surgery
Often Said:
If you are not having complications;
You are not doing surgery
Implying
Complications are Inevitable & little can
be done to prevent them
They are expected

13. Safety & Bariatric Surgery
Fear Complacency
• When surgeons Don’t
rigorously adhere to
• Rules/Checklist in managing
patients, their team &
themselves

14. Safety & Bariatric Surgery
Complacency
• Error:
Neglect careful
attention
• pre, Intra & post-op
management guidelines
• (e.g. Leak Prevention
Rules)

15. Safety & Bariatric Surgery
Fear Complacency
• Even worse,
• Some surgeons choose
to operate knowing of
major problems with
their patient or their
team
• (Misunderstand
Seriousness of
Complications)

16. Examples of Complacency
Sleeve Gastrectomy Leak
• “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

17. “Risk of leak is low at 2.4%"
Imagine an Airline
Releases the following statement:
“Risk of Airplane Crashes are Low at only 2.4%"

18. The Mindset of
Commitment to Excellence
Make the Commitment
To yourself and to your
Patient:
“Failure is Not an Option”

19. Objectives
Adoption of Mindset to
Prevent Complications
(Failure is Not & Option)
Fight Complacency
Specific Techniques to
AVOID complications
1. Know your Enemy (List Complications)
2. Management of Complications

20. FIRST:Don’t Manage Complications?
Prevent, Prevent, Prevent

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

22. Volume Performance
New Surgeons = More Complications

23. Complications Decrease
with Experience

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

25. Learning Minimally-Invasive Mitral Valve Surgery
• The typical number of operations to
overcome the learning curve was between
75 & 125 operations
• Furthermore, more than one such operation
per week was necessary to maintain good
results.
• Individual learning curves varied markedly
proving the need for good monitoring and/or
mentoring in the initial phase.
•
Circulation. 2013 Jun 26. Learning Minimally-Invasive Mitral Valve Surgery: A Cumulative Sum
Sequential Probability Analysis of 3895 Operations from a Single High Volume Center Holzhey
DM, Seeburger J, Misfeld M, Borger MA, Mohr FW. Heart Center Leipzig, Leipzig, Germany

26. 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.

27. Surgeons' experience with laparoscopic fundoplication
• Complications of laparoscopic fundoplication
are more likely during the initial 20 cases
• Experience with the procedure
shorter operating time & fewer
complications, conversions, & early
dysphagia
•
Surg Endosc. 2007 Aug;21(8):1377-82. Epub 2007 Feb 7. Surgeons' experience with
laparoscopic fundoplication after the early personal experience: does it have an impact on the
outcome? Salminen P, Hiekkanen H, Laine S, Ovaska J. Department of Surgery, Turku University
Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland. paulina.salminen@tyks.fi

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

29. Unacceptable Outcomes
Revisional Surgery After Failed Or
Complicated Sleeve
Early complication rate 23.4%;
Staple line leak 5.4%,
Bleeding was 8.1%
Obes Surg. 2012 Dec;22(12):1903-8. Indications & short-term outcomes of revisional surgery after
failed or complicated sleeve gastrectomy. van Rutte PW, Smulders JF, de Zoete JP, Nienhuijs
SW.Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ,
Eindhoven, The Netherlands.

30. Laparoscopic sleeve gastrectomy for failed
laparoscopic adjustable gastric band
800 patients underwent LSG, with 90 as
a revisional procedure for failed LAGB
Operative complications included
5.5 % leak & 4.4 % hemorrhage
Conclusions: “We advocate this
procedure as
a good bariatric option (?)
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

31. Bariatric Surgery Complications
Leak
Bleeding
Venous thrombosis/PE
Infections, Pneumonia
SBO from abdominal hernia
Stricture/Obstruction
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

32. Leak Prevention
Leak Location:
EG Junction (Think Sleeve)
Prevention: Simple:
AVIOD EG Junction!

33. 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"
(NO NO NO)
Prevention: Simple:
AVIOD the EG Junction!

34. Learning from Sleeve Leak Experience
In 75-95% the leak
location near the
gastro-esophageal
junction
Prevention:
Simple:
FEAR the
EG Junction!

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

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. 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

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

40. Leak:
Prevention/Treatment
Bring in Good Healthy
Vascularized Tissue

41. Omentum in esophagogastric anastomosis
for prevention of anastomotic leak
•Leak in 3 pts with omentum
wrapped around the anastomosis
patients (3.1%)
•14 (14.4%) patients leaked without
using the omental patch
•Ann Thorac Surg. 2006 Nov;82(5):1857-62. Use of pedicled omentum in
esophagogastric anastomosis for prevention of anastomotic leak.Bhat MA,
Dar MA, Lone GN, Dar AM. Department of Cardiovascular and Thoracic
Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir,
India. drmakbarbhat@yahoo.co.uk

42. Omental reinforcement for
intraoperative RNY leak repair
•387 patients with 32 (8.26%) patients who
had a staple line dehiscence or evidence of
gastric pouch or gastrojejunostomy leak
intraoperatively.
•Leaks/dehiscences were repaired with
sutures and then reinforced with omentum.
•No leak Omental Patch Pts
•Am Surg. 2009 Sep;75(9):839-42. Omental reinforcement for intraoperative leak repairs during
laparoscopic Roux-en-Y gastric bypass. Madan AK, Martinez JM, Lo Menzo E, Khan KA, Tichansky
DS. Division of Laparoendoscopic and Bariatric Surgery, Daughtry Family Department of Surgery,
University of Miami, Miller School of Medicine, 1475 NW 12th Avenue, Suite 4017, Miami, FL 33136,
USA. atulkmadan@yahoo.com

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

44. 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

45. 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.

46. Do Not Be Confused
There are Two Kinds of Leaks
1. Easy Leaks
2. Terrible Disasters
How to tell the difference:
Easy = 24 -48 hours
Terrible Disasters = All others

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

48. Leak Management
Leak found 24-48hr
= Suture Repair
Leak Found More than 72 hours
= Trouble

49. Sleeve Leak
• Where does it
occur?
• ONE PLACE!
• This is “Tiger
Country” –
remember that!

50. Sleeve Leak
• Where does it
occur?
• ONE PLACE!
• For this to heal
What has to
happen?

51. Prevent Leaks
Do Not Become Knowledgeable
in Treating Leaks

52. Sleeve Leaks
•
•
•
•
•
Early Diagnosis and Treatment
Ideally re-explore 24-48 hours
Late Leak
Stable vs Infected/Septic
Stable NPO, NG Across the Leak,
GI or IV Feeding, ABx, + Drainage

53. Sleeve Leaks
• Late Leak
• Infected/Septic
• NPO, NG Across the Leak, GI or IV
Feeding, ABx, +Drainage
• Consider re-exploration

54. Sleeve Leaks
•
•
•
•
Debride Necrotic Tissue.
Drain abscess(s)
Consider:
Isolated Roux limb as a serosal
patch to cover EG junction defect
or as a side to side Thal patch
• Enteral Feeding Tube Below Leak

55. Sleeve Leaks
• The serosal side of jejunum (Thal
patch), Bring the Roux limb up to the
injured portion of the EG Junction
• A Roux-Y limb of jejunum, with its
independent blood supply and normal
healthy tissue may help control the
leak by bringing in Healthy tissue to the
EG Junction area

56. Sleeve Leaks
• Acute conversion of Leaking
Sleeve to MGB is not advised
• The theoretical advantage
decreasing the back pressure of
the pylorus is not necessary when
the esophagus, stomach pouch
and gut are appropriately drained