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LEAKS IN BARIATRIC SURGERY Paolo Gentileschi Bariatric Surgery Unit University of Rome Tor Vergata.

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Presentazione sul tema: "LEAKS IN BARIATRIC SURGERY Paolo Gentileschi Bariatric Surgery Unit University of Rome Tor Vergata."— Transcript della presentazione:

1 LEAKS IN BARIATRIC SURGERY Paolo Gentileschi Bariatric Surgery Unit University of Rome Tor Vergata

2 LEAKS IN BARIATRIC SURGERY

3 + 142%

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5

6 LEAKS

7 Mortalità < 30 giorni (precoce) : 0,28% > 30 giorni (tardiva) : 0,35% Pazienti SuperObesi: Mortalità Precoce: 1,25% Mortalità Tardiva: 0,81% Pazienti con età> 65 anni Mortalità Precoce: 0,34% Mortalità Tardiva: 0,0%

8 Postoperative Adverse Events by Bariatric Procedure in Controlled Trials. Maggard M A et al. Ann Intern Med 2005;142:

9 Local and Systemic Factors that negatively influence suture integrity

10 Leaks 0-6 % Sleeve Gastrectomy Sleeve Gastrectomy

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12 LEAK RATE BY PROCEDURE LAGB 0% LSG 0-7% LRYGB 0-7% LBPD 0-6%

13 RCTs

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16 Int’l Consensus Summits on Sleeve Gastrectomy

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22 Comparative Use of Different Techniques for Leaks and Bleeding prevention during Laparoscopic Sleeve Gastrectomy M.Anselmino, N. Basso*, P. Gentileschi°, L. Angrisani§, G. Casella°, D. Benavoli°, S. D’Ugo°, P. Cutolo§, C. Moretto, R. Bellini, R.D. Berta, S. Franceschi Bariatric & Metabolic Surgery Unit, Pisa *VII Dept. of Surgery, Rome La Sapienza §Dept. Of General Surgery, S. G. Bosco Hospital, Naples °Bariatric Surgery Unit, Rome Tor Vergata

23 CenterCityInvestigator A.O.U.P.PisaAnselmino S. Giovanni BoscoNaplesAngrisani Tor Vergata UniversityRomeGentileschi La Sapienza UniversityRomeBasso All cases of primary SG in 4 Italian Bariatric Centers

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25 Company Synovis SICovidienGoreBaxter Product Brand NamePeri-Strips Dry with Veritas Duet TRSSEAMGUARD Bioabsorbable FLOSEAL TISSEEL MaterialBovine Pericardium Synthetic polyester (Biosyn material) Glycolide and Trimethylene Carbonate Copolymer Thrombine Haemostatic matrix + Fibrin Glue Host Tissue Response RemodelsReabsorbs - Tissue thicknessAvg = 0.35 mm 0.20 – 0.60 mm Avg = 0.07 mm 0.04 – 0.10 mm 0.25 mm - Tensile strength (Peak load) 4.0 kgTBD1.2 kg - StorageControlled room tempAmbient room temp Preparation One piece; requires gel application Pre-loaded on stapler loads; attached with Biosyn sutures Two pieces; sleeves fit on stapler arms COMPETITIVE LANDSCAPE

26 Reinforcement Type

27 Results

28 CONCLUSIONS No evidence at this time for minor incidence of leaks with either materials or oversewing -Sufficient evidence of less episodes of bleeding with reinforcement with either strips

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30 LEAKS

31 Laparoscopic Sleeve Gastrectomy

32 SERIES (Policlinico Tor Vergata Roma) March LSG (primary) 6 LEAKS (1.5%)

33 Laparoscopic Sleeve Gastrectomy 5 healed with : 2 with laparoscopic drainage and TPN 3 with endoscopic clipping and stenting 1 Mortality : Pulmonary failure and sepsis

34 IL BY-PASS GASTRICO

35 Complicanze dopo By Pass gastrico sec. Roux Precoci (entro 30 giorni) Tardive Fistola 2-7% Fistola 2-7% Embolia polmonare 0,2-1% Embolia polmonare 0,2-1% Infezione ferita 8% Infezione ferita 8% Emorragia 0,8-4,4% Emorragia 0,8-4,4% Insufficienza respiratoria 1- 4% Insufficienza respiratoria 1- 4% Ernia ferita chirurgica 12-15% Ernia ferita chirurgica 12-15% Occlusione intestinale 1-3% Occlusione intestinale 1-3% Stenosi delle anastomosi 3-7% Stenosi delle anastomosi 3-7% Anemia da carenza di Ferro e/o vitamimina B12 e/o acido folico 15-33%* Anemia da carenza di Ferro e/o vitamimina B12 e/o acido folico 15-33%* Osteoporosi da carenza di calcio 8-10% * Osteoporosi da carenza di calcio 8-10% * Ulcera marginale 1-16% Ulcera marginale 1-16%

36 LEAKS DOPO BY-PASS GASTRICO Serie (Policlinico Tor Vergata) Marzo pz 1 leak anastomosi gastro-digiunale (0.2%) Re-intervento, drenaggio, NPT 1 leak anastomosi entero-entero (0.2%) Re-intervento, riconfezionamento

37 STENTING STENTING

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39 La II causa più comune di morte dopo RYGB Leak Anastomosi G-J : Leak Anastomosi G-J : Incidenza 2-5% Incidenza 2-5% - LRYGB: 5,2% - LRYGB: 5,2% - ORYGB:2,6% - ORYGB:2,6% Mortalità 1,5% Mortalità 1,5% Tempo medio per la diagnosi: 2 giorni Leak anastomosi J-J Leak anastomosi J-J Mortalità: 40% Tempo Medio per la diagnosi: 4 giorni Diagnosi Leak anastomotici Segni e/o Sintomi: Dolori addominale Tachicardia Iperpiressia Aumentati segni di flogosi: VES, PCR, ProCalcitonina Leucocitosi Neutrofila Distress respiratorio Studio Radiologico: Rx digerente con Gastrografin Tc con mdc per os Complicanze Precoci: Leak Anastomotici

40 Leak Anastomotici Trattamento Pz Stabile No segni di shock settico, No segni di ampio Leak Trattamento Conservativo Digiuno Digiuno NPT NPT Antibtioticoterapia e.v. Antibtioticoterapia e.v. SNG SNG STENT STENT Presenza di Raccolta Addominale Drenaggio percutaneo TC-guidato Pz Instabile Segni shock Settico Segni radiologici di ampio LeackReintervento Relaparoscopia Laparotomia Lavaggio raccolte intraddominali Posizionamento di Drenaggi Aspirativi Sutura diretta Leak

41 Treated 19 patients with removable covered stents -acute leaks (n=11) -chronic fistulas (n=2) -strictures (n=6) Leaks were identified endoscopically, marked radiographically, and stents deployed under fluoroscopy. Oral feeding could be started in 79% of the patients after stenting. At a follow up of 3.6 months successful healing was achieved in : 91% of acute leaks 100% of gastrocutaneous fistulas 81% of strictures Mean healing time of 30 days

42 Treatment of Leaks and Other Bariatric Complications with Endoluminal Stents Treatment of acute fistola Infected fluid collection Percutaneus or laparoscopic dranaige Acute fistola Applications of stents were extended to treat esophageal and gastrointestinal leaks Healed anastomotic leak after stent removal

43 LEAKS PREVENTION APPROPRIATE SURGICAL TECHNIQUE STAPLE LINE REINFORCEMENT (?) suture buttress material sealants MET BLUE TESTING NG TUBE (?) DIAGNOSIS ENDOSCOPY WITH FLUOROSCOPY CT SCAN TREATMENT CONSERVATIVE Drainage TPN STENTING Endoscopic clipping or sealants (?)


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