Clinical predictors of leak after laparoscopic Roux-enY gastric bypass for morbid obesity

Leaks after esophagojejunostomy for patients with gastric cancer who underwent total gastrectomy or after gastrojejunostomy for morbid obesity that leaves a gastric pouch smaller than 20 ml can be classified as a type 1 (small localized leaks) or type 2 leak (with enteric spill or discharge of contrast material, or enteric content through the abdominal drain to the exterior or fully to the abdominal cavity) as we reported previously [1]. Although type 1 fistulas are seen as often or more frequently than type 2 leaks, they have minor clinical importance. The only way to know if they occur is by performing routinely contrast studies after surgery.

The authors and most surgeons performing this type of surgery use a soluble contrast such as Gastrografin, which easily dilutes so that its capacity to detect small leaks is very low. In fact the authors report only two of nine leaks detected by Gastrografin, which clearly means that it should not be used. For 25 years we have used barium sulphate routinely the fifth day after surgery detecting 100% of the leaks after 614 total gastrectomies and 420 resectional gastric bypass. Barium sulphate gives an excellent, clear radiologic view for early detection of abnormality, allowing surgeons to proceed in treating patients according to the findings. The idea that there is no complication with the use of barium is a myth. If there is free spillage to the abdominal cavity the patient should undergo reoperation immediately. Although clinical signs are very useful for indicating abdominal leaks, other septic conditions such as infected atelectasis, pneumonia, or fatty necrosis in obese patients may present with a very similar clinical condition. I do not understand the “hurry” of American surgeons to discharge patients or 3 days after such an important operation. Anastomotic leaks very rarely occur 1 day after surgery, but rather occur 3 to 5 days after surgery when the patient can be at home. That is why I believe radiologic studies the day after surgery, are useless. I am more conservative, discharging in the patients 6 to 7 days after surgery. This allows most of the complications that may occur after surgery to happen while patients are under careful medical control and not at home.