Abstract
Background
Leak or stenosis following laparoscopic Roux-en-Y gastric bypass (LRYGB) can lead to a major morbidity. We aim to evaluate whether the routine use of intraoperative endoscopy (IOE) can reduce this morbidity.
Methods
All cases of LRYGB in 2009–2014 were reviewed. In all cases, we perform an IOE. If IOE shows a leak, the area of the leak is re-enforced and IOE is repeated. If the leak persisted, a feeding tube and drains are placed.
Results
During the study period, we performed 342 LRYGB cases. Primary LRYGB represented 82 % (282/342). Average BMI 48 kg/m2 (range was 35–92) and females represented 76 % (261/342). Our clinical leak rate was 3/342 (0.88 %) in LRYGB (0.4 % in primary and 3.3 % in revisional LRYGB). IOE showed a positive air leak test in six LRYGB cases (1.75 %). We were able to achieve a negative leak test after re-enforcement in 5/6 (83 %) cases, and all those patients had no clinical leak. The patient with persistent air leak test had a clinical leak after surgery. IOE was negative in 336 LRYGB cases and we had two clinical leaks in this group (0.59 %). Our stenosis rate at the gastrojejunostomy was 3/342 (0.88 %). The positive predictive value (PPV) of the performing IOE to detect leaks in LRYGB was 75 % while the negative predictive value was 99.5 %.
Conclusions
Routine IOE has led to a change in the operative strategy and could be one reason for our low leak and stenosis in laparoscopic Roux-en-Y gastric bypass.
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References
Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–52.
Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753–61.
Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons–Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410.
Nguyen NT, Masoomi H, Magno CP, et al. Trends in use of bariatric surgery, 2003–2008. J Am Coll Surg. 2011;213(2):261–6.
Maher JW, Martin Hawver L, Pucci A, et al. Four hundred fifty consecutive laparoscopic Roux-en-Y gastric bypasses with no mortality and declining leak rates and lengths of stay in a bariatric training program. J Am Coll Surg. 2008;206(5):940–4.
Sims TL, Mullican MA, Hamilton EC, et al. Routine upper gastrointestinal Gastrografin® swallow after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003;13(1):66–72.
Quartararo G, Facchiano E, Scaring S, et al. Upper gastrointestinal series after Roux en Y gastric bypass for morbid obesity: effectiveness in leakage detection. A Systematic Review of the Literature. Obes Surg. 2014 May 11.
Maher JW, Bakhos W, Nahmias N, et al. Drain amylase levels are an adjunct in detection of gastrojejunostomy leaks after Roux-en-Y gastric bypass. J Am Coll Surg. 2009;208(5):881–4.
Sensenig D, Jurgeleit H. The use of methylene blue solution to test for leaks in gastric bypass operations for morbid obesity. J Maine Med Assoc. 1980;71(8):234.
Nimeri A, Mohamed A, el Hassan E, et al. Are results of bariatric surgery different in the Middle East? Early experience of an international bariatric surgery program and an ACS NSQIP outcomes comparison. J Am Coll Surg. 2013;216(6):1082–8.
Fernandez Jr A, DeMaria E, Tichansky D, et al. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc Interv Tech. 2004;18(2):193–7.
Dallal RM, Bailey L, Nahmias N. Back to basics—clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary. Surg Endosc. 2007;21(12):2268–71.
Madan A, Stoecklein H, Ternovits C, et al. Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass. Surg Endosc. 2007;21(2):194–6.
Sapala JA, Wood MH, Schunhkencht MP. Anastomotic leak prophylaxis using a vapor heated fibrin sealant: report on 738 gastric bypass patients. Obes Surg. 2004;14(1):35–42.
Wendling MR, Linn JG, Keplinger KM, et al. Omental patch repair effectively treats perforated marginal ulcer following Roux en Y gatric bypass. Surg Endosc. 2013;27(2):384–9.
Jacobsen HJ, Nergard BJ, Leifsson BG, et al. Management of suspected anastomotic leak after bariatric laparoscopic Roux en gastric bypass. Br J Surg. 2014;101(4):417–23.
Haddad A, Tapazoglou N, Singh K, et al. Role of intraoperative esophagogastroenteroscopy in minimizing gastrojejunostomy-related morbidity: experience with 2,311 laparoscopic gastric bypasses with linear stapler anastomosis. Obes Surg. 2012;22(12):1928–33.
Champion J, Hunt T, DeLisle N. Role of routine intraoperative endoscopy in laparoscopic bariatric surgery. Surg Endosc Interv Tech. 2002;16(12):1663–5.
Ramanathan R, Ikramuddin D, Gourash W, et al. The value of intraoperative endoscopy during laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2000;14:212.
Finks JF, Carlin A, Share D, et al. Michigan bariatric surgery collaborative. Effects of surgical technique on clinical outcomes after laparoscopic gastric bypass—results of the Michigan bariatric surgery collaborative. Surg Obes Relat Dis. 2011;7(3):284–9. doi:10.1016/j.soard.2010.10.004.
Alasfar F, Sabnis AA, Liu RC, et al. Stricture rate after laparoscopic Roux-en-Y gastric bypass with a 21-mm circular stapler: the Cleveland Clinic experience. Med Princ Pract. 2009;18(5):364–7.
Dolce CJ, Dunnican WJ, Kushnir L, et al. Gastrojejunal strictures after Roux-en-Y gastric bypass with a 21-mm circular stapler. JSLS J Soc Laparoendosc Surg. 2009;13(3):306–11.
Giordano S, Tolonen P, Victorzon M. Comparision of linear versus circular stapling techniques in laparoscopic gastric bypass surgery—a pilot study. Scand J Surg: SJS: Off Organ Finn Surg Soc Scand Surg Soc. 2009;99(3):127–31.
Go MR, Muscarella P, Needleman BJ, et al. Endoscopic management of stomal stenosis after Roux en Y gastric bypass. Surg Endosc. 2004;18(1):56–9.
Gonzalez R, Lin E, Venkatesh KR, et al. Gastrojejunostomy during laparoscopic gastric bypass: analysis of 3 techniques. Arch Surg. 2003;138(2):181–4.
Conflict of Interest
Drs. Al Hadad, Dehni, Elamin, Ibrahim, Ghabra, and Nimeri have no conflicts of interest or financial ties to disclose. For this type of study, a formal consent is not required.
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Al Hadad, M., Dehni, N., Elamin, D. et al. Intraoperative Endoscopy Decreases Postoperative Complications in Laparoscopic Roux-en-Y Gastric Bypass. OBES SURG 25, 1711–1715 (2015). https://doi.org/10.1007/s11695-015-1604-z
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DOI: https://doi.org/10.1007/s11695-015-1604-z