Managing complications v4

Managing Complications

First Prevent Complications

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

Safety & Bariatric Surgery Complacency

• When surgeons Don’t rigorously adhere to pre-op rules or checklist in selecting & preparing their patient, their team & themselves


• Error: Neglect careful attention

• pre, Intra & post-op management guidelines

• (e.g. Re-exploration Rules)


• Even worse, some surgeons choose to operate knowing of major problems with their patient or their team

• (Misunderstand Serious of Complications)

Examples of ComplacencySleeve Gastrectomy Failure:

• “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

Laparoscopic revisional surgery after Roux-en-Y

Revision of RNY

Patients required surgical exploration for hemorrhage, staple line leak, and an incarcerated hernia.

The overall complication rate was 23%, with a major complication rate of 11.5%

Surg Obes Relat Dis. 2010 Sep-Oct;6(5):485-90. Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy. Morales MP, Wheeler AA, Ramaswamy A, Scott JS, de la Torre RA. Department of Surgery, University of Missouri, Columbia, Missouri 65203, USA.

“Risk of leak is low at 2.4%"

Air India Airlines

Releases the following statement:

“Risk of Airplane Crashes are Low at only 2.4%"

The Mindset of Commitment to Excellence

Make the CommitmentTo your Patient:

“Failure is Not an Option”

Objectives

Adoption of Mindset to Prevent Complications (Failure is Not & Option)

Fight ComplacencySpecific Techniques to

AVOID complications1. Know your Enemy (List Complications)2. Management of Complications

Don’t Manage a Complication? Prevent, Prevent, Prevent

Complication Managementvs.

Complication Prevention

Better to Prevent a Leak than to be

Expert in Managing a Leak

Volume PerformanceNew Surgeons = More Complications

Complications Decreasewith Experience

New Surgeons are Dangerous & Deadly Surgeons

Complications decline to logarithm of the surgeons’

Training & Experience

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

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 12-

year 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.

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. [email protected]

What can we learn from the Airline Industry

Failure is Not an Option

PE PreventionArgument for Prophylaxsis

Most patients who die from PE do so within 30 minutes of onset, leaving little time for diagnosis or effective intervention.

"... further reductions in mortality from pulmonary embolism must come through systematic prophylaxis in high-risk patients rather than a policy of 'wait & treat'"

Gallus AS (1990) Baillieres Clin Haematol 3, 651-684.

Two general types of prophylaxis mechanical methods &

pharmacological agents.

Graded compression stockings have been shown to be effective

Should be fitted individually to ensure that pressure is correctly graded

Bleeding and LMWH

At least eight randomized studies compared LMWH with standard heparin in patients undergoing abdominal surgery.

A number of the early trials evaluating prophylactic LMWH reported excessive bleeding

Fear Bleeding with LMWH:“If” Used: BE CAREFUL

Enoxaparin is given at a dose of 30 mg twice a day,

First dose 12 hours after surgery

And…There is currently much interest in continuing to administer LMWHs for a longer period after surgery to protect against the longer-term threat of thrombosis. (Risk of “Late” PE)

Prevention of Venous Thromboembolism American College of Chest Physicians

2.5 Laparoscopic Surgery2.5.1. For patients undergoing entirely

laparoscopic procedures who do not have additional

thromboembolic risk factors, we recommend against the routine use of

thromboprophylaxis,other than early & frequent ambulation(Grade 1B).


2.5.2. For patients undergoing laparoscopic procedures in whom additional VTE risk factors are present,

Recommend prophylaxis • LMWH, fondaparinux, • Intermittent Pneumatic Compression • Graded Compression Stockings


2.6 Bariatric Surgery2.6.1. For patients undergoing inpatient bariatric

surgery, we recommend routine thromboprophylaxis with LMWH, LDUH three times daily, fondaparinux, or the combination of one of these pharmacologic methods with optimally used intermittent pneumatic compression (IPC). (each Grade 1C).

2.6.2. For patients undergoing inpatient bariatricsurgery, we suggest that higher doses of LMWHor LDUH than usual for nonobese patients beused (Grade 2C).


Prevention of Venous Thromboembolism American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

Chest 2008;133;381S-453S

Cascade Effect

Laparoscopic Surgery VTE Prophylaxsis

Vs.

Bariatric Surgery VTE Prophylaxsis


2.0 General, Vascular, Gynecologic, Urologic, Laparoscopic, Bariatric, Thoracic, & Coronary Artery Bypass Surgery

2.1 General Surgery2.1.1. For low-risk general surgery patients who

are undergoing minor procedures & have no additional thromboembolic risk factors,

we recommend against the use of specific thromboprophylaxis other than early & frequent ambulation (Grade 1A).

2.5 Laparoscopic Surgery

2.5.1. For patients undergoing entirely laparoscopic procedures who do not have additional thromboembolic risk factors, we recommend against the routine use of thromboprophylaxis, other than early & frequent ambulation (Grade 1B).

2.5.2. For patients undergoing laparoscopic procedures in whom additional VTE risk factors are present, we recommend the use of thromboprophylaxis with one or more of LMWH, LDUH, fondaparinux, IPC, or GCS (all Grade 1C).

Surgery VTE Prophylaxsis

The 8th edition of the ACCP guidelines recommends that mechanical methods of VTE prophylaxis be used primarily in patients who are at high risk of bleeding & that careful attention be directed to ensuring their proper use & optimal adherence.

Mechanical compression should be initiated prior to induction of anesthesia & continue intraoperatively & then into the postanesthesia care unit.

Surgery VTE Prophylaxsis

Fondaparinux was associated with an increase in bleeding events & instances of transfusion requirement,

Low molecular weight heparin Increases Bleeding Complications 3X

179 pts gastric surgery Rx LMWH (3200u qd 2-6 h preop til DC), 182 pts controls.

No patient in either group developed VTE

LMWH significantly higher complication rate (27% vs. 15.4%, p=0.005)

Postop bleeding & wound complications sig. higher in LMWH pts

Multivariate analysis LMWH independent risk factor (odds ratio, 3X, P = 0.009) of postop

Ann Surg Oncol. 2010 Sep;17(9):2363-9. The effect of low molecular weight heparin thromboprophylaxis on bleeding complications after gastric cancer surgery. Jeong O, Ryu SY, Park YK, Kim YJ. Division of Gastrointestinal Surgery, Department of Surgery, Chonnam National University Hwasun Hospital, Jeollanam-do, Korea

Bleeding Complications

Laparoscopic sleeve gastrectomy (LSG) is one of the most common procedures of bariatric surgery.

Complications after LSG are commonMost frequent is bleeding

LSG-associated gastric leak & hemorrhages remain the most important challenges postoperatively

Indications & short-term outcomes of Revisional Surgery After Failed Or

Complicated Sleeve

Early complication rate in the whole cohort was 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.

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 % hemorrhageConclusions: “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

Pre-operative administration of Enoxaparin

Coagulation parameters increased significantly & similarly at 30 min & 6 h with both treatments, but

Returned to normal 12 hIF using EnoxaparinEnoxaparin 100 UI/Kg (IDEAL BWt) x BID s.c.

Stop min 12 h before surgery(i.e. Rx morning Day Before Surgery & Restart

morning After Surgery)

GI AnastomosisStapled vs Hand Sewn

Adhesion formation was less extensive, & histologic evidence of inflammation was less severe, in stapled anastomoses.

The average times required to complete the simple interrupted, simple continuous, & stapled anastomoses were 22, 14, & 8 minutes, respectively.

Cornell Vet. 1988 Oct;78(4):325-37. A comparison of three methods of end-to-end anastomosis in the equine small colon. Bristol DG, Cullen J.

Department of Food Animal & Equine Medicine, North Carolina State University, School of Veterinary Medicine, Raleigh 27606

Early Complications & Long Term Reoperation Rates

Complications RNY/Band (9% vs 5%)

Long-term reop rate RNY/Band(16% vs 24%)

MGB 5% Comp. 1-2% Reop

Am J Med. 2008 Oct;121(10):885-93. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD.Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94143-1732, USA. [email protected]

Nutrient Deficiencies

The most frequent deficiencies after restrictive procedures are related to B-vitamins whereas

Iron, folate, vitamin B1 & B12 & vitamin D deficiencies are associated with the malabsorptive procedures

Zentralbl Chir. 2013 Jul 3. [Nutrient Deficiencies after Bariatric Surgery - Systematic Literature Review & Suggestions for Diagnostics & Treatment.] [Article in German] Stroh C, Benedix F, Meyer F, Manger T.Klinik für Allgemein-, Viszeral- und Kinderchirurgie, SRH Wald-Klinikum Gera gGmbH, Gera, Deutschland

Post Op Complications

Frequent complicationsSleeve gastrectomy & gastric bypasses may

present with life-threatening suture leaks or suture line bleeding

Gastric bypass & BPD Marginal ulcer, bleeding, Perforation, Stenosis, Abscess, Bowel obstruction, internal hernia, also caused by trocar site hernia, intussusceptions, adhesions, strictures, kinking, or blood clots.

Rapid weight loss after bariatric surgery can cause cholecystitis or choledocholithiasis

RNY/MGB Post Op Complications

Complication RNY% MGB%

Bleeding 2.6 0.2%

Leak 2.4 0.2%

Wound infection (requiring hospital treatment) 2.2 0.1%

Intestinal obstruction 1.1 0.0%

Intra-abdominal abscess 0.7 0.1%

Pulmonary thromboembolism 0.6 0.2%

Total of early complications 9.6 0.8%

Controlled Prospective Randomized Trial Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus Mini-

Gastric Bypass for the treatment of Morbid Obesity. Ann Surg 2005 ; 242 : 20-28

RYG Bypass Mini Bypass

Op time (mns) 205 148

Early complications 20% 7.5%

Late complications 7.5% 7.5 %

EWL at one year 58.7% 64.9%

EWL at two years 60% 64.4%

Laparoscopic Mini Gastric Bypass

Cesare Peraglie MD FACS FASCRSCLOS-Florida: Heart of Florida Regional Medical Center.

Davenport, [email protected]

SECO 2012BARCELONA SPAIN

Laparoscopic-Mini Gastric Bypass: HOFRMC

•Over 1000 Laparoscopic MGB’s have been performed at HOFRMC since 2005.

•TYPICAL DEMOGRAPHICS: AGE: 45 (14-72), BMI: 45 (30-75), ~27% DIABETIC, ~50% HTN, ~31% PREVIOUS ABDOMINAL SURGERY

•OUTCOMES OP-TIME: 62Min. (37-186), Conversion to open: 0 LOS: 1 DAY or less (88%), 2 DAY (10%), 3 DAY (~2%), 4+

DAY (<1%) Re-admission: 5% (23 hour obs. PONV in all but one) /

0.8% 90 day Leak: 0.3% MORTALITY: 0 (HOSPITAL), 0 (PERI-OP:90D)

MGB Outcomes

Tissue adhesives in gastrointestinal anastomosis

48 studies

Iileal & gastric/bariatric anastomosis reveals promising results for fibrin glue

J Surg Res. 2013 Apr;180(2):290-300. doi: 10.1016/j.jss.2012.12.043. Epub 2013 Jan 16.Tissue adhesives in gastrointestinal anastomosis: a systematic review.Vakalopoulos KA, JF.Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands. [email protected]

Fibrin glue as a sealant forRNY Gastric Bypass

The fibrin sealant group No leaks /120pts

5 pts/120 No Fibrin, Surgeon B,

2 pts/120 No Fibrin, Surgeon C,

1 pt/120 Surgeon A without fibrin sealant Obes Surg. 2003 Feb;13(1):45-8.Fibrin glue as a sealant for high-risk anastomosis in surgery for

morbid obesity.Liu CD, Glantz GJ, Livingston EH.University of California, Los Angeles School of Medicine & Greater Los Angeles VA Medical Center, Department of Surgery, Los Angeles, CA 10833, USA. [email protected]

Fibrin glue as a sealant forRNY Gastric Bypass

A prospective, randomized, multicenter, clinical trial commenced in January 2004

No leaks or internal hernias in the fibrin glue group.

The incidence of leaks (2 cases, 1.8%) & the overall reoperation rate were higher in the control group (P=0.0165).

Obes Surg. 2006 Feb;16(2):125-31.Clinical evaluation of fibrin glue in the prevention of anastomotic leak & internal hernia after laparoscopic gastric bypass: preliminary results of a prospective, randomized multicenter trial.Silecchia G, Boru CE, Mouiel J, Rossi M, Anselmino M, Tacchino RM, Foco M, Gaspari AL, Gentileschi P, Morino M, Toppino M, Basso N.Dipartmento di Chirurgia Generale Paride Stefanini, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy. [email protected]

Stapled vs Handsewn Anastomosis

Linear Stapled vs Handsewn Esophago-Gastrostomy

Anastomotic leak:

1 (3.0%) of 33 stapled

13 (14.4%) of the 90 Hand Sewn

(P = 0.07) Surg Today. 2009;39(3):201-6. The triangulating stapling technique for cervical esophagogastric anastomosis after

esophagectomy Toh Y, Sakaguchi Y, Ikeda O, Adachi E, Ohgaki K, Yamashita Y, Oki E, Minami K, Okamura T.Department of Gastroenterological Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan

Early & late feeding on healing of anastomoses

2 groups: late feeding (LF) & early feeding (EF)

LF group was fed parenterally for 6 days & orally (per oral route) after postop day 7

EF group was fed orally (per oral route) 24h postop

LF group, Bursting Pressure & Esophageal Diameter lower than EF

Early feeding is superior

NSAIDs be abandoned after primary GI anastomosis

Anastomotic leak (AL) is the most important & one of the most serious complications after GI anastomosis

Factors that contribute to increase the risk of AL should be identified and--if possible--eliminated

Prostaglandins promote neo-angiogenesis & enhanced wound healing

Non-steroidal anti-inflammatory drugs (NSAIDs) are often used for treating pain after surgical procedures


Retrospective, case-control study in 75 patients undergoing laparoscopic colorectal resection for colorectal cancer.

33 of these patients received the NSAID diclofenac in the postoperative period

42 did not receive any NSAID. There were significantly more LEAKS among

the patients receiving diclofenac (7/33 vs. 1/42, p=0.018)


Database study based on data from the Danish Colorectal Cancer Group's (DCCG) prospective database & electronically registered medical records.

From the database information on demographic, surgical & postoperative variables (including AL) were provided.

Information on NSAID consumption was retrieved by individual searches in the patients' medical records.

Based on these data, uni- & multivariate logistic regression analyses were performed.

These analyses identified NSAID treatment in the postoperative period as an individual risk factor for Leak

Billroth II Outperforms RNY following Pancreaticoduodenectomy

Delayed gastric emptying (DGE) is one of the major complications after pancreaticoduodenectomy (PD), occurring in 14% to 61%

Randomly allocated to B-II reconstruction (n = 52) & R-Y reconstruction (n = 49) groups

Delayed gastric emptying occurred in 5.7% of patients in the B-II 20.4% of patients in the R-Y (P = 0.03)B-II shorter hospital stay than R-Y (31 days vs. 41, P =

0.04)

Ann Surg. 2013 May;257(5):938-42 Effect of billroth II or Roux-en-Y reconstruction for the gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled study. Shimoda M, Kubota K, Katoh M, Kita J. Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan. [email protected]

MGB/RNY/SG Complications

Short term:LeakBleedingVenous thrombosisInfections, PneumoniaSBO from abdominal herniaAnastomotic strictureTechnical ErrorsArq 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. [email protected]

Leak Prevention

Leak Location:EG Junction (Think Sleeve)

Prevention: Simple: AVIOD e.g. Junction!

Gastro JejunostomyPrevention: Technical Details of Laparoscopic GI anastomosis(Remember the Basics of General Surgery)

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

Prevention: Simple:

AVIOD the EG Junction!

Learning from Sleeve Leak Experience

In 33 of the patients (75%), the leak

location near the gastroesophageal

junction

Prevention: Simple:

FEAR the EG Junction!

Leak Prevention

ALWAYS DO A SAFE ANASTOMOSIS

Preop Factors

Intra-op Factors

Post Op Factors

Leak Prevention

ALWAYS DO A SAFE ANASTOMOSIS

Not leak.Cause no persistent bleeding.Cause no stricture of the lumen.Create no risk for internal hernia.

Patient Factors

Look for these factors:Correct these factors or REJECT the Patient1. Renal/Cardiac/Pulmonary Dysfunction2. Bacterial contamination3. Inflammation4. Shock & hypoperfusion states5. Diabetes mellitus6. Chronic steroid use7. Poor nutritional status8. Malignancy

Fundamentals of Gastro-Intestinal Anastomosis Healing

NO NSAIDs, Steroids, Anti-Metabolites (fluorouracil decreased anastomotic breaking strength by more than 40%)

Accurate Fluid AdministrationSTOP SmokingAdequate Vitamin A levelsAggressive Control of Glucose LevelsEarly feeding liquid protein & caloriesPreop StatinsPreop Creatine SupplementsPreop Exercise (Increase Testosterone, HGH)Supplemental Oxygen in All patients


Adequate local blood supply (Carefully maintain mesentery)

Elimination of tension (Long Pouch,left gutter for bowel)

Meticulous Hemostasis (avoid damage to staple line)

Gentle & precise handling of tissuesClosure of mesenteric defects (Not in MGB)Close inspectionAccurate Suture Placement (NOT Many Sutures,

3 layers are not better)


Adequate local blood supply

Maintain mesentery

Elimination of tension Long PouchLeft gutter for bowel


Meticulous Hemostasis

SLOW Staple Gun Firing

Avoid damage to staple line

Do Not Touch the Staple Line

Gentle & precise handling of tissues


Inverted vs. Everted 1800s, Lembert, Halsted

advocated an inverted, serosa-to-serosa anastomosis

Hand-sutured everting bowel anastomosis point out

Simplicity & decreased risk of bowel lumen narrowing

Animal experiments in the 1960s & 1970s demonstrated no difference in healing strength & leak rates between the two approaches


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.

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 leakThe common staple height for the small bowel

& colon is 3.5 blue, 3.5 mm For the thicker stomach, green, 4.8 mm


1 Layer, Maybe 2, Not More (Ischemia)

Remember your general surgery

Inverted => Narrowing of the Lumen & early complaints of Nausea & Vomiting Patient complaints, stress on the anastomosis & prolonged hospitalization

Stapled vs Handsewn

Buttress/Fibrin Glue/Omental Patch?

Meta-analysis of randomized controlled trials single- vs two- layer intestinal anastomosis

Six trials were analyzed, comprising 670 participants (single-layer group, n = 299; two-layer 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

Note:NO ONE Recommends 3 or 4 Layer

AnastomosesNo Staple Company Recommends

Oversewing the Staple Line

Decreasing RNY anastomotic and staple line leak

•All operations were performed using a linear-stapled anastomosis with •buttressing material, handsewn otomy closures, stay sutures, •intraoperative leak testing, and •fibrin sealant•Surg Endosc. 2009 Jun;23(6):1403-8. Decreasing anastomotic and staple line leaks after laparoscopic Roux-en-Y gastric bypass. Fullum TM, Aluka KJ, Turner PL. Department of Surgery, Howard University College of Medicine, Washington, DC, USA. [email protected]

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. [email protected]

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. [email protected]

Prevent Bleeding:“Go Slow

to Go Fast”

Case Mantra:“No Bleeding”“Easy Case”

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

Stapler Use

WarningsEnsure 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.

Management Leaks

Simple:In ANY Post Op Patient with ANY

ComplaintsDo: RexploreDo Not: WBC, CXR or other Plain FilmDo Not: CT Scan or Gastrograffin

SwallowThe Only Answer Rexplore

Leak Management

Leak found 24-48hr

= Suture Repair

Leak Found More than 72 hours

= Take down GJ

= Gastro-Gastrostomy

Bleeding Management

Rexplore

Bleeding site:

Staple line etc = suture repair and drain

Bed of spleen = aspirate hematoma and direct pressure 20-30 minutes

Drain and rexplore if necessary

Nausea Vomiting Abdominal Distention

Rexplore

Etiology

Kink, Twist, Stricture etc

Rx Take down GJ

Revision of GJ

Abdominal Abscess Minimal Sx

Drain Percutaneous and Antibiotics

Marginal UlcerDyspepsia/”Bile Reflux”

99% of Cases Sx are from ACID Peptic Gastritis/Ulcer

Rx SAME as for ANY PEPTIC ULCERRemove Causes; Smoking, NSAIDs etc.Add Probiotics (Curd Yogurt etc)PPIs (Prilosec etc)Antacids (Carafate, Mylanta etc)Rx H. Pylori


Iron Def Anemia:

Common in Young women, NOT in Men

Why? Menstrual Losses

Therefore:

Rx FIRST slow / eliminate menstrual loss

Refer to GYN for Rx

Second Oral Iron “Proferrin”


B12 Def Anemia:

Common India

Why? Dietary

Therefore:

Rx Oral or IM B12

Long Term Nutrient Deficiencies

Calcium Deficiency

Rx Daily Yogurt/Curd

Best source Calcium, probiotics (Lactobacillus) and protein

Education

Managing complications v4