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This prevention covers the updated Endoscopic and Endolumenal treatment of Roux-and-Y Gastric Bypass leaks and fistulas in a comprehensive manner with the published experience of a very active reference center with over 20 peer-reviewed articles over this matter of bariatric endoscopy
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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
