LINEE GUIDA PER IL RINFORZO DELLE
SUTURE IN CHIRURGIA BARIATRICA
Leakage/fistole e sanguinamento dalle linee di sutura:
siti ed incidenza
Luigi Angrisani
Director - General and Endoscopic Surgery Unit
S.Giovanni Bosco Hospital, Naples, Italy
“S.GIOVANNI BOSCO” EXPERIENCE
N=1109 Pts
148
160
140
120
120
106
100
74
80
56
60
40
20
33
20
19
12
0
0
28
27
39
28
1
4
69
62
36
31
6
21
3
18
3
68
15
9
67
19
37
6
15
6
25
18
37
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Gastric Banding
Gastric Bypass
Sleeve Gastrectomy
Angrisani 2013
Leak is reported in 1-7 % of patients
Leak rate 1.5% (75% GE junction)
Prevention
1) Not too tight sleeve (using larger bougies ≥ 40fr)*
2) Firing the stapler lateral to the angle of His
3) Performing an intraoperative leak test
*
*
Conclusions
• Mean leak rate 2.4% (range 0-7%)
• 92% at the GE junction
• 79% of leaks occurred more than 10 days
postoperatively
• Super-obese pts leak rate 2.9% vs morbid obese
patients leak rate 2.2% (not significant p>0.05)
• Stricture rate: 0.5%
• Bleeding rate: 0.7%
• Boogie size of <40Fr is associated with increased
risk of leak
• Oversewing or buttressing of the staple line does not
have a clinically significant effect on leaks
Aurora A et al. Surg Endosc (2012) 26:1509-1515)
Techniques used for LSG
Effect of technique on leak rate
Overall leak rate: 2.2%
Conclusions
1) Leak rate of approximately 2.4%
2) Clinically significant bleeding and stricture rate of less
than 1%
3) Leak at GE junction 89%
4) Greater risk of leak in BMI > 50 kg/m2
5) Greater risk of leak with smaller bougies (<40 Fr)
6) Oversewing or buttressing of the staple line does not have
a clinically significant effect on leak
ANTI -OBESITY PROCEDURES
n= 1932
Jan 1996 - Dec 2012
100
495
326
510
24
459
Lap Band System®
Bioenterics Intragastric Balloon®
Sleeve Gastrectomy
Gastric Bypass
BPD-Duodenal Switch
Revisions
ANGRISANI 2013 Naples, Italy
RESULTS
 Complications: intraoperative leaks in SG pts
 N=2/495 (0,4%)
 Intra-Operative conversion to:
1 pt*
1pt
Roux en Y limb
Roux-en-Y GBP
with
with
Sub-Total Gastrectomy
Distal Stomach
Preservation
* Band removal 1 year before
ANGRISANI 2013 Naples, Italy
Leak rate: 17/1133 (1.5%)
p value: not statistically significant
Laparoscopic Roux en Y Gastric Bypass
N=510 (Jan 2000 – Dec 2012)
•Mortality
1 (0,2%)
•Laparotomic Conversion
4 (0.8%)
•Gastro-jejunal Leak
2 (0,4%)
•Gastro-jejunal Stenosis
3 (0,6%)
•Mean Operative Time
140  25 min
•Hospital Stay
5  2 days
General and Endoscopic Surgery Unit
“S. Giovanni Bosco” Hospital - Naples - Italy
Director: Luigi Angrisani
Laparoscopic Roux en Y Gastric Bypass
REOPERATIONS 22/510 (4.3%) Jan 00- Dec 12
Internal hernia
Bowel perforation
Jejuno-jejunostomy stenosis
Bowel obstruction / Adhesions
Intussusception
Hemoperitoneum
Protein malnutrition
N=11
N=3
N=2
N=2
N=2
N=1
N=1
General and Endoscopic Surgery Unit
“S. Giovanni Bosco” Hospital - Naples - Italy
Director: Luigi Angrisani
CONCLUSIONS
 The healing time of a SG leak is longer than
GBPs’ leak
 Even if the rate of complications of GBP & SG is
similar, those after SG appear to have a worse
outcome leading to more aggressive procedures
(Total/distal gastrectomy)
 Revisional procedures have an increased risk of
leak versus primary procedures.
Angrisani-Formisano 2013