BARIATRIC SURGERY BOWEL LEAK

                                           

Gastro-jejunostomy                                                                                    Jejuno-Jejunostomy

( Schauer www.laparoscopy.com)

SMALL BOWEL OBSTRUCTION

Small bowel Obstruction occurs in 5-7% of patients It is almost always the result of a technical error and thus often seen early in the learning curve of a surgeon. The sites leading to obstruction are the gastro-jejunostomy the jejuno-jejunostomy and internal hernias caused by failure to adequately close the intrnal defects caused by creation of the Roux en Y
The high rate of stricture at the Gastro-jejunostomy is reduced by careful hand sewn anastomosis. Obstruction at the jejunojejunostomy. Is often the result of narrowing caused by the linesr stapler as well as kinking. Some surgeons have recommended hand suturing in order to reduce the incidence of obstruction(see Suter et al). Another technique to prevent a kink at the anastomosis is the use of “ the anti-obstruction stitch” described by Brolin, (American Journal of Surgery, 169 355.)

Use of anti-obstruction stitch reported by Brolin has been shown to reduce jejunojejunostomy stricture as this stricture is more common with laparoscopic approach than the open technique (as noted by Jones et al.). . Nguyen and colleagues reported four early bowel obstructions in their first 80 cases. They attributed this complication to the application of the linear stapler to close the jejunojejunostomy enterotomy defect in three of the four obstructions. The fourth obstruction was caused by failure to place the anti-obstruction suture and thus, leading to a kink of the anastomosis.
 

Failures to close respective sites for internal hernia were also resulted in high rate of intestinal obstruction Internal hernias occur in three locations, Through the mesenteric defect that is created in a transverse mesocolon, at the level of the mesentery of the jejunojejunostomy and behind the Roux limb also called Peterson's hernia. The creation of an antecolic antegastric limb rather than a retro-colic placement resulted in no internal hernias or scar formation at the level of the mesenteric defect. However, it results in a more frequent formation of gastrojejunostomy stricture.
Stricture of the gastrojejunostomy noted in 9 percent of the patients in the series, and respond well to endoscopic management. When obstruction is not relieved bowel perforation and leak will ensue

POTENTIAL SITES FOR INTERNAL HERNIAS

( Schauer www.laparoscopy.com)

                                    Small bowel perforation and leak

One of the major cause of mortality after RYGB is gastrojejunostomy leak. It is reported in up to 3% of cases, and is often due to technical errors or failure of stapling device. Patients present themselves early with symptoms which are often subtle like anxiety and mild tachycardia. The air bubble test used intra-operatively not always predicts a future leak. The decision to return patient to the operating room is primarily based on clinical grounds with or without the aid of radiographic studies.
Because signs and symptoms of bowel leak are often subtle it is crucial that patient will seek immediate medical care. Papasavas et al concluded that it is crucial to instruct patients to seek appropriate follow up by bariatric surgeon since many physicians are not familiar with the subtle presentation and challenging management for these potentially catastrophic medical problems. A follow up by the bariatric surgeon is of extreme importance. As long as bariatric surgery is evolving the surgeon cannot assume that follow up care by the referring physician is adequate.
Hamilton et al from the University of Texas in Dallas ( surgical endoscopy 2003 17 679,) ) reviewed their experience with 210 consecutive patients. Of the 210 patients, 9 patients (4.3%) sufferd from gastrointestinal leak. They observed that the presence of respiratory distress and heart rate exceeding a 120 beats per minute were the two most positive indicators of gastrointestinal leak. Routine upper gastrointestinal contrast imaging detected only two of the nine leaks,
( 22%). The sensitivity of tachycardia is demonstrated by the observation that 90% of the patients who leaked had severe tachycardia of over 120 beats per minutes as compared to only 16% of those who did not experience a leak. Fewer than one-fourth of the patients who leaked had any temperature elevation and none had a high temperature. Respiratory distress was six times more common in the patients who leaked. A marginal urinary output. Was also seen in patients with leak. Severe abdominal pain was noted in only one-third of the patients' leaks. Many obese patients do not demonstrate the typical peritoneal signs seen in non-obese patients.( Hamilton et al)
 

The utilization gastrographin to diagnose a leak was disappointing. In case of a leak, physician use gastrographin rather than barium because if barium leaks into the peritoneal cavity it causes severe chemical peritonitis. Gastrographin is useful in detecting gastro-jejunostomy leak but rarely detect jejuno-jejunostomy leaks because it is diluted by the large amount of intestinal fluids present during bowel obstruction. Failure to demonstrate a leak during gastrographin study should not lull the surgeon to believe that no leak is present. CT scan is much more helpful. A computer tomography was positive when upper UGI was negative showing fluid collection or extravasation of contrast material. Many centers perform a gastrographin swallow study in the first post operative day. The study while informative does not mean that a leak at a later day may not occur.

Hamilton et al noted that 78% of patients who leaked did not have a leak at the first day contrast study.
As noted by Hamilton et al early exploration in patients who demonstrate tachycardia ( >120) tachypnea and low urinary output will identify the majority of patients suffering from bowel leak and reduce the high mortality associated with this dreadful complication. . There were no non-therapeutic laparotomies in all cases. . Hamilton et al concluded: "attempts to rule out diagnoses other than gastrointestinal leak, should not delay resuscitative efforts, and the return of the patient to the operating room to avert intra-abdominal catastrophe”.

 Marshall et al, (archives of surgery, volume 138, May 2003, page 520) reported 400 consecutive gastric bypass procedures done in the Community Hospital with the University surgical residents. They reported that 21 patients (5.2%) developed leaks, 13 at the gastrojejunal anastomosis with an average time to diagnosis of seven days. Seven underwent re-exploration and eight were successfully treated with percutaneous drainge. Four patients developed leak at the jejunojejunal anastomosis with mean time of diagnosis of two days. All of these patients required exploration and two patients died. Four patients were noted to have leaks in other areas with average time of diagnosis 3.5 days. They concluded that unstable patients ( usually jejun-jejunostomy leaks) require emergent exploration, leaks that are more insidious ( usually Gastro-jejunostomy) may be treated successfully with percutaneous To benefit from this approach, the patient must be clinically stable without hypertension or oliguria.


 

ABOUT THE AUTHOR

1
Social Security Disability Tucson Arizona