Minimally invasive management of anastomotic leak after bariatric Roux-en-Y gastric bypass.

The aim of this retrospective study was to examine the anastomotic erosion due to drain and success of fibrin sealant in its management. Between 2013 and 2014, 102 patients underwent LRYGB and gastrojejunal anastomotic leak occurred due to drain erosion in 2 of them. The diagnosis was established with saliva drainage and was confirmed by upper gastrointestinal series. The absence of hemodynamic instability was directed us to conservative treatment. During the endoscopy, dehiscence was assessed and fibrin sealant was applied. The leaks healed progressively in a few days, and the drains removed within 6 days. Seven and 9 days later, the patients were discharged without any problem. Anastomotic leaks after bariatric surgery can cause severe morbidity, cost, and effects quality of life. Hemodynamically stable and drained patients are candidates for conservative methods. Endoscopic injection of fibrin sealant has been successful in closing gastric leaks.

INTRODUCTION

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently the most commonly performed bariatric surgical Procedure.[1] Anastomotic leaks and pulmonary embolism are the two most feared complications in patients undergoing LRYGB.[2] Routine use of abdominal drains after LRYGB is still practiced by many bariatric surgeons with the goals of earlier diagnosis of complications such as bleeding and leaks.[3] A variety of drain-related problems have been reported in various types of abdominal surgeries.-[456] Different therapeutic options have been reported in the literature for anastomotic leakages after LRYGB. Some authors have recommended laparoscopic primary repair[78] or immediate reoperation by laparotomy with the intention of primarily closing the defect.[9] Others have recommended endoscopic treatment with clips,[10] fibrin glue,[11] plugs,[12] endoluminal vacuum therapy,[13] self-expanding metallic stents.[14]

In this study, we present two cases of the fistula caused by erosion of the drain into the gastrojejunal anastomosis to the gastric pouch. The fistulas treated endoscopically by closing the gastric hole with fibrin sealant injection.

Patients

Since January 2013 to April 2014, 102 morbidly obese patients have been treated with LRYGB in our clinic. Of these, two patients were managed for anastomotic leakage related to erosion of drain.

Patient 1

First patient was a 50-year-old woman without any additional disease or previous abdominal operation. The preoperative body mass index (BMI) was 50.4, and the American Society of Anesthesiology (ASA) score was II [Table 1]. Preoperative endoscopic examination of the stomach and duodenum were normal. LRYGB was performed with hand-sewn procedure. The operative time was 90 minutes with negligibly blood loss. A nasogastric tube was placed to check the anastomosis with methylene blue and a 26 French silicone tube was placed behind the gastrojejunostomy (GJ) anastomosis to provide abdominal drainage. The patient was monitored in the intensive care unit. A leakage was diagnosed on postoperative day 3 in the presence of saliva drainage with no tachycardia, fever or hemodynamic failure. Initially daily drainage volume was 300 ml. The upper gastrointestinal (UGI) series with water-soluble contrast showed a filiform leak and the drain catheter was evacuating contrast totally [Figure 1].

Table 1

Demographic data of the patients

Figure 1

Gastrojejunal leak along drain, (a) Patient 1, (b) Patient 2

Patient 2

Second patient was a 31-year-old woman with a preoperative BMI of 61, and the American Society of Anesthesiology (ASA) score was II. On gastroduodenoscopic examination there was no pathology. The patient underwent LRYGB. Two operations were performed on the same day, and the same operative procedure was applied. Approximately 300 ml daily flow rate of a leakage was observed on postoperative day 4. Patient's oral intake was stopped, and total parenteral nutrition (2500 kcal/24h) was added to treatment. The amount of drainage on the 10th day fell to 150 ml, and gastroscopic examination and covered metallic stent placement or fibrin sealent therapy were planned. The gastroscopy demonstrated the presence of the drain catheter inside the gastric pouch, and drainage catheter was withdrawn 5 cm [Figures 2a and b]. Region of leakage was regular edged and small. Therefore, leakage was treated with endoscopic fibrin sealant injection (4 ml of TISSEEL; Baxter Healthcare, Norfolk, UK) [Figures 2c and d]. The fistulas healed progressively and oral nutrition was authorized on fifth day after endoscopic intervention. All of the drains were removed on sixth day. The patients were discharged on seventh and ninth day.

Figure 2

Endoscopic findings. (a) The drain was inside the gastric pouch. (b) Drain was withdrawn. (c) Injection of fibrin sealant. (d) The gastric pouch wall defect was occluded by fibrin glue

DISCUSSION

Intraperitoneal drainage after gastrointestinal surgery is still routinely used. Some authors reported that many gastrointestinal operations can safely be performed without routine drainage.[15] However, use of drainage gives credence to the surgical team and we performs gastrointestinal operations with routine drainage for early diagnose of the bleeding or intestinal leaks.

Postoperative leaks after LRYGB increases mortality and morbidity. This complication therefore induces a higher rate of repeat operations, prolongs the hospital stay, and impairs quality of life.[16] In the LRYGB, the most common site for anastomotic leak is at the proximal anastomosis (gastrojejunostomy). However, enteric leaks may occur at any site along any staple line. The reported rate for anastomotic leak after LRYGB ranges from 0 to 5.2% in recent studies.[171819] Various treatment methods have been proposed in the intestinal leakage.[7891011121314] Many of these methods are applied in our clinic for selected patients with intestinal leakage. In the present study, intestinal perforations were developed due to a drainage catheter. The operations were performed in the same day and the same type silicone tube was used as a drain. Spyropoulos et al. reported that 90% of the leaks could be managed by non-operative techniques.[20] According to the study by Csendes et al., conservative treatment, with antibiotics, and parenteral nutrition were employed in near 65% of the patients.[16] More recently, some bariatric surgeons have been dealing to manage GJ leaks nonoperatively in the absence of sepsis or hemodynamic instability. The mainstay of this treatment involves monitoring of secretions through the drains, use of intravenous antibiotics, and total parenteral nutrition. This approach has been shown to be successful and decreases the morbidity associated with a reoperation.[21] Therefore, we choose the conservative methods in our cases. Endoscopic injection of fibrin sealant provides safe and successful treatment of patients who develop gastric leaks after bariatric operations and some authors suggested to reinforce the anastomosis by fibrin glue.[22] After these two cases, we use a softer and thinner drain to avoid the possibility of pressure erosion.

CONCLUSION

The literature including endoscopic treatment options in case of GJ leaks following LRYGB operations is not insufficient. Most publications tend to recommend an early reoperation. In our opinion, a nonoperative endoscopic treatment option may be a better strategy in the absence of hemodynamic instability. Use of soft drains and immediate endoscopic treatment may provide healing of the defect and shorten the time for closure, and it may save the life of the patient.