Postsleeve Gastrectomy Leak / Surgery for Obesity and Related Diseases 10 (2014) 106–111
111
Editorial comment
Comment on: The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks Chour et al. [1] present a unique approach to the management of the most difficult problem encountered by bariatric surgeons performing sleeve gastrectomy in their practice. Their study emphasizes the fact that there is no perfect solution to the management of proximal sleeve gastrectomy leaks, which is a vexing situation. Sleeve gastrectomy is associated with a leak rate of 2.6% (range 0%–7%), of which most (89%) appear in the proximal sleeve, close to the gastroesophageal junction [2]. Of these, 79% present after patient discharge. Because the number of sleeve gastrectomies performed in the nation is increasing, gradually more and more surgeons are facing the challenge of managing leaks of the staple line. As reported by the International Sleeve Gastrectomy Expert Panel [3], many surgeons manage an acute leak within the first 2 days by repeat surgical closure. Early and late leaks are usually managed effectively with the use of a combination of endoscopic stenting and external drainage. Most surgeons believe that any chronic leak persisting beyond a month is unlikely to heal with the use of stenting and drainage alone, and will need repeat surgical intervention in the form of conversion to a Roux-en-Y gastric bypass or, rarely, total gastrectomy and esophagojejunal anastomosis. Use of a Roux limb to control a leak after sleeve gastrectomy was first described by Baltasar et al. [4] in 2007. Chour et al. [1] similarly present this technique to control a proximal gastrectomy leak and also propose proceeding with this technique at an early stage to prevent chronic morbidity and increased hospitalization associated with delayed control of leak. I agree that creation of a Roux limb over the leak site should have a lower risk compared with a complete Roux-en-Y gastric bypass, because it avoids an additional staple line in an already inflamed stomach. It also provides low pressure drainage of the proximal stomach in a tight sleeve (most proximal leaks are associated with a stricture in mid-stomach and are associated with high pressures within the proximal portion of the stomach). However, do not expect the gastrojejunal anastomosis to heal immediately; there was a small leak at this anastomosis, as well, in 3 of 6 patients (50%), which healed spontaneously after a mean duration of 11 days. The presence of a healthy jejunum with a good blood supply probably explains the rapid healing of this anastomosis.
Other European authors have also proposed this technique for management of proximal leaks [5,6]. However, these authors have performed this procedure 44 months after the index operation. As mentioned in the International Expert Panel Consensus Statement, 94% of surgeons believe that a wait of at least 12 weeks is needed before reintervention to avoid difficult to manage adhesions. The suggestion by Chour et al. [1] to intervene early (after 4 weeks of failed conservative therapy) to decrease the healthcare cost was based on their experience with only 2 patients and needs further validation. I suspect this would be difficult to perform in a patient who is still morbidly obese and has dense adhesions forming around the fistula. In conclusion, placement of a Roux limb over the proximal leak after sleeve gastrectomy is now a well-described technique to manage a chronic leak. However, its early use after 4 weeks of failed conservative therapy needs further evolution and should be performed only by experienced surgeons. Pradeep Kumar Pallati, M.D. Creighton University Medical Center Omaha, Nebraska
References [1] Chour M, Alami RS, Sleilaty F, Wakim R. The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks. Surg Obes Relat Dis 2014;10:106–10. [2] Aurora AR, Khaitan L. Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012;26:1509–15. [3] Rosenthal RJ. International Sleeve Gastrectomy Expert Panel, Diaz, AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19. [4] Baltasar A, Bou R, Bengochea M, Serra C, Cipagauta L. Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy. Obes Surg 2007;17:1408–10. [5] van de Vrande S, Himpens J, El Mourad H, Debaerdemaeker R, Leman G. Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement. Surg Obes Relat Dis. Epub 2013 Jan 16. [6] Nedelcu AM, Skalli M, Deneve E, Fabre JM, Nocca D. Surgical management of chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis. Epub 2013 Mar 14.
111
Editorial comment
Comment on: The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks Chour et al. [1] present a unique approach to the management of the most difficult problem encountered by bariatric surgeons performing sleeve gastrectomy in their practice. Their study emphasizes the fact that there is no perfect solution to the management of proximal sleeve gastrectomy leaks, which is a vexing situation. Sleeve gastrectomy is associated with a leak rate of 2.6% (range 0%–7%), of which most (89%) appear in the proximal sleeve, close to the gastroesophageal junction [2]. Of these, 79% present after patient discharge. Because the number of sleeve gastrectomies performed in the nation is increasing, gradually more and more surgeons are facing the challenge of managing leaks of the staple line. As reported by the International Sleeve Gastrectomy Expert Panel [3], many surgeons manage an acute leak within the first 2 days by repeat surgical closure. Early and late leaks are usually managed effectively with the use of a combination of endoscopic stenting and external drainage. Most surgeons believe that any chronic leak persisting beyond a month is unlikely to heal with the use of stenting and drainage alone, and will need repeat surgical intervention in the form of conversion to a Roux-en-Y gastric bypass or, rarely, total gastrectomy and esophagojejunal anastomosis. Use of a Roux limb to control a leak after sleeve gastrectomy was first described by Baltasar et al. [4] in 2007. Chour et al. [1] similarly present this technique to control a proximal gastrectomy leak and also propose proceeding with this technique at an early stage to prevent chronic morbidity and increased hospitalization associated with delayed control of leak. I agree that creation of a Roux limb over the leak site should have a lower risk compared with a complete Roux-en-Y gastric bypass, because it avoids an additional staple line in an already inflamed stomach. It also provides low pressure drainage of the proximal stomach in a tight sleeve (most proximal leaks are associated with a stricture in mid-stomach and are associated with high pressures within the proximal portion of the stomach). However, do not expect the gastrojejunal anastomosis to heal immediately; there was a small leak at this anastomosis, as well, in 3 of 6 patients (50%), which healed spontaneously after a mean duration of 11 days. The presence of a healthy jejunum with a good blood supply probably explains the rapid healing of this anastomosis.
Other European authors have also proposed this technique for management of proximal leaks [5,6]. However, these authors have performed this procedure 44 months after the index operation. As mentioned in the International Expert Panel Consensus Statement, 94% of surgeons believe that a wait of at least 12 weeks is needed before reintervention to avoid difficult to manage adhesions. The suggestion by Chour et al. [1] to intervene early (after 4 weeks of failed conservative therapy) to decrease the healthcare cost was based on their experience with only 2 patients and needs further validation. I suspect this would be difficult to perform in a patient who is still morbidly obese and has dense adhesions forming around the fistula. In conclusion, placement of a Roux limb over the proximal leak after sleeve gastrectomy is now a well-described technique to manage a chronic leak. However, its early use after 4 weeks of failed conservative therapy needs further evolution and should be performed only by experienced surgeons. Pradeep Kumar Pallati, M.D. Creighton University Medical Center Omaha, Nebraska
References [1] Chour M, Alami RS, Sleilaty F, Wakim R. The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks. Surg Obes Relat Dis 2014;10:106–10. [2] Aurora AR, Khaitan L. Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012;26:1509–15. [3] Rosenthal RJ. International Sleeve Gastrectomy Expert Panel, Diaz, AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19. [4] Baltasar A, Bou R, Bengochea M, Serra C, Cipagauta L. Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy. Obes Surg 2007;17:1408–10. [5] van de Vrande S, Himpens J, El Mourad H, Debaerdemaeker R, Leman G. Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement. Surg Obes Relat Dis. Epub 2013 Jan 16. [6] Nedelcu AM, Skalli M, Deneve E, Fabre JM, Nocca D. Surgical management of chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis. Epub 2013 Mar 14.
