Ask the Experts: Dilemmas in Bariatric Surgery
This month’s dilemma:
Managing a leak after sleeve gastrectomy
This month’s expert:
Kelvin Higa, MD
Bariatric Times. 2010;7(1)10–11
This ongoing column is dedicated to providing information to our readers on various dilemmas in bariatric surgery. We invite questions from our readers. The answers are provided by experts in the field.
A 43-year-old man presented with a few-hour history of drainage from abdominal wall. He had a history of a gastric band placement, which resulted in erosion. The band was removed and converted to sleeve gastrectomy. He subsequently developed a leak after the sleeve gastrectomy. He was treated with conservative management with limited oral intake and total parenteral nutrition. In addition, a stent was placed endoscopically. The current computer tomograpy scan shows a leak from the staple line with an intraabdominal collection/fistula.
How long should one wait after removing a gastric band before performing another bariatric procedure, such as a sleeve gastrectomy?
In the case of erosion, it would be controversial to perform a sleeve gastrectomy synchronously to the band explant. It is inconceivable to imagine a situation where one could delineate the site of erosion and repair it while obtaining the anatomic construct to expect performance from the sleeve gastrectomy. In the absence of erosion, synchronous band removal and revision to another operation has been reported. What is not clear is whether or not removing the band and waiting an arbitrary amount of time would result in fewer complications.
Also, there is significant individual variation in the inflammatory response to the band-making explanations, and subsequent reoperations are unpredictable. Compounding this is the inevitable weight recidivism and uncertainty of insurance authorization for subsequent revision.
It is safe, in many cases, to perform a synchronous band removal and revision operation (except in the case of erosion) subject to the experience and skill of the surgeon and anatomic challenges presented by each individual patient. How long one should wait in the case of staged procedures is anybody’s guess.
Which procedure is recommended after removal of a gastric band and sleeve gastrectomy versus gastric bypass?
The best revision operation after a failed band is yet to be determined. In the case of inadequate weight loss, sleeve gastrectomy or gastric bypass have been shown to be effective, but long-term data (>10 years) has not been reported. In the case of complications of the band, such as reflux or erosion, I think that gastric bypass offers better control of the reflux and, in the case of erosion, buttressing the exposed gastric staple line with the Roux limb may decrease the rate of fistulas.
Of course, one must always consider the biliopancreatic diversion as a revision, especially in the case of severe metabolic syndrome.
Are there any recommendations as far as stent placement for leaks after sleeve gastrectomy?
Much is talked about stents for leaks after sleeve gastrectomy, but only because options are limited in this situation. Covered stents are subject to migration and patient intolerance. Many times, the stent does not control the leak completely. Despite these drawbacks, intraluminal stent placement along with good surgical drainage continues to be the best first-line option in the case of leak after sleeve gastrectomy.
What is the recommended management of this patient at this time?
This patient clearly needs another operation. Either the stent is not controlling the leak or the drain is not properly placed. Prior to surgery, this patient needs to be evaluated for distal obstruction either at the pylorus (vagotomy from band erosion or subsequent surgical injury?) or proximal due to narrowing or angulation of the sleeve. The site of the leak in relation to the esophagogastric junction and the presence or absence of a hiatal hernia is important in planning the next operation.
If there is a hiatal hernia, and there almost always is, then there is usually enough stomach above the staple lines to perform a gastric bypass, resecting the fistula and establishing enteral feeding. If the leak is at or above the esophagogastric junction, I would not perform a Roux-en-Y esophagojejunostomy at this stage; rather, establish good drainage and enteral feeding. If there is relative outlet obstruction, then Roux-en-Y diversion is mandatory.
About the expert
Dr. Higa is Clinical Professor in Surgery, UCSF-FRESNO, Director, Bariatric and Minimally Invasive Surgery, Fresno, California.
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