Endolumenal strategies on RYGB leaks

LEAKS IN RYGB

JOSEMBERG CAMPOS, PHDMANOEL GALVAO NETO, MDALMINO C. RAMOS, MD

Recife, PE, Brazil

Sao Paulo, SP, Brazil

Sao Paulo, SP, Brazil

Recife, PE, Brazil

ALMINO CARDOSO RAMOS MANOELA GALVÃO MANOEL GALVÃO NETO ANDREY CARLO

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

• 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.

• 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.

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.

Leaks / Fistulas

RNY Gastric Bypass leaks

GASTRO-ENTERO“POUCH” GASTRO-ENTERO

RNY Gastric Bypass leaks

Gastro-Cutaneous fistula

Gastro-gastric fistula

RNY Gastric Bypass leaks

RNY Gastric Bypass leaks

Gastro-Bronqueal fistula

First control the sepsis

Laparoscopy

Percutaneous

Laparotomy

Stabilize the patient

RNY Gastric Bypass leaks

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….

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

Endoscopic balloon dilation

RNY Gastric Bypass leaksDilate first

RYGB Leaks Stents

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

Bariatric upper leaksPlastic- Silicon

Implant…

Removal…

Bariatric upper leaksMetallic single covered- Nitinol

Bariatric upper leaksProsthesis – New modelsNitinol double covered…

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

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

RYGB Leaks Complementary procedures

Septomy

Septomy

CAUTERY + PNEUMATIC DILATIONRESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)

Septomy

CAUTERY + PNEUMATIC DILATIONRESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)

RYGB Leaks Endoscopic treatment can be used even on the worst

scenarios

Fístula Gastrobronchial

Obes Surg, 2011

Sleeve Gastrectomy - Complications

Thanks!galvaon@gmail.com