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01-03-2016

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy

Authors: Monica Sethi, Jonathan Zagzag, Karan Patel, Melissa Magrath, Eduardo Somoza, Manish S. Parikh, John K. Saunders, Aku Ude-Welcome, Bradley F. Schwack, Marina S. Kurian, George A. Fielding, Christine J. Ren-Fielding

Published in: Surgical Endoscopy | Issue 3/2016

Abstract

Background

Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy.

Methods

A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses.

Results

A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8 %), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7 %) cases, while 221 (14.3 %) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1 %) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1 %, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1–67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative.

Conclusion

Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

Nguyen NT, Nguyen B, Gebhart A, Hohmann S (2013) Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 216:252–257CrossRefPubMed

Gagner M, Buchwald JN (2014) Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review. Surg Obes Relat Dis 10:713–723CrossRefPubMed

Nannipieri M, Baldi S, Mari A, Colligiani D, Guarino D, Camastra S, Barsotti E, Berta R, Moriconi D, Bellini R, Anselmino M, Ferrannini E (2013) Roux-en-Y gastric bypass and sleeve gastrectomy: mechanisms of diabetes remission and role of gut hormones. J Clin Endocrinol Metab 98:4391–4399CrossRefPubMed

Fridman A, Moon R, Cozacov Y, Ampudia C, Lo Menzo E, Szomstein S, Rosenthal RJ (2013) Procedure-related morbidity in bariatric surgery: a retrospective short- and mid-term follow-up of a single institution of the American College of Surgeons Bariatric Surgery Centers of Excellence. J Am Coll Surg 217:614–620CrossRefPubMed

Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, Matter I, Alfici R, Mahajna A, Waksman I, Shimonov M, Assalia A (2013) Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 27:240–245CrossRefPubMed

Tan JT, Kariyawasam S, Wijeratne T, Chandraratna HS (2010) Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg 20:403–409CrossRefPubMed

Mizrahi I, Tabak A, Grinbaum R, Beglaibter N, Eid A, Simanovsky N, Hiller N (2014) The utility of routine postoperative upper gastrointestinal swallow studies following laparoscopic sleeve gastrectomy. Obes Surg 24:1415–1419CrossRefPubMed

Aggarwal S, Kini SU, Herron DM (2007) Laparoscopic sleeve gastrectomy for morbid obesity: a review. Surg Obes Relat Dis 3:189–194CrossRefPubMed

Aurora AR, Khaitan L, Saber AA (2012) Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 26:1509–1515CrossRefPubMed

10.

Rosenthal RJ, International Sleeve Gastrectomy Expert P, Diaz AA, Arvidsson D, Baker RS, Basso N, Bellanger D, Boza C, El Mourad H, France M, Gagner M, Galvao-Neto M, Higa KD, Himpens J, Hutchinson CM, Jacobs M, Jorgensen JO, Jossart G, Lakdawala M, Nguyen NT, Nocca D, Prager G, Pomp A, Ramos AC, Rosenthal RJ, Shah S, Vix M, Wittgrove A, Zundel N (2012) International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 8:8–19CrossRefPubMed

11.

Wu PY, Kang TJ, Hui CK, Hung MH, Sun WZ, Chan WH (2006) Fatal massive hemorrhage caused by nasogastric tube misplacement in a patient with mediastinitis. J Formos Med Assoc 105:80–85CrossRefPubMed

12.

de Aretxabala X, Leon J, Wiedmaier G, Turu I, Ovalle C, Maluenda F, Gonzalez C, Humphrey J, Hurtado M, Benavides C (2011) Gastric leak after sleeve gastrectomy: analysis of its management. Obes Surg 21:1232–1237CrossRefPubMed

13.

Aggarwal S, Bhattacharjee H, Chander Misra M (2011) Practice of routine intraoperative leak test during laparoscopic sleeve gastrectomy should not be discarded. Surg Obes Relat Dis 7:e24–e25CrossRefPubMed

14.

Mittermair R, Sucher R, Perathoner A, Wykypiel H (2014) Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary. Am J Surg 207:897–901CrossRefPubMed

15.

Bellanger DE, Greenway FL (2011) Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 21:146–150CrossRefPubMed

16.

Christian D, Barba C, Burke-Martindale C (2004) A simple bedside evaluation to detect gastroesophageal leaks after gastric bypass surgery. Surg Endosc 18:S193 (abst) CrossRef

17.

Ovnat A, Peiser J, Solomon H, Charuzi I (1986) Early detection and treatment of a leaking gastrojejunostomy following gastric bypass. Isr J Med Sci 22:556–558PubMed

18.

Gagner M, Deitel M, Erickson AL, Crosby RD (2013) Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg 23:2013–2017CrossRefPubMed

19.

Jen S, Simillis C, Efthimiou E (2013) A very challenging leak from a sleeve gastrectomy. Surg Obes Relat Dis 9:e56–e59CrossRefPubMed

20.

Gonzalez R, Nelson LG, Gallagher SF, Murr MM (2004) Anastomotic leaks after laparoscopic gastric bypass. Obes Surg 14:1299–1307CrossRefPubMed

21.

Casella G, Soricelli E, Rizzello M, Trentino P, Fiocca F, Fantini A, Salvatori FM, Basso N (2009) Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 19:821–826CrossRefPubMed

22.

Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M (2013) Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 257:231–237CrossRefPubMed

23.

Gagner M, Deitel M, Kalberer TL, Erickson AL, Crosby RD (2009) The Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009. Surg Obes Relat Dis 5:476–485CrossRefPubMed

24.

Alaedeen D, Madan AK, Ro CY, Khan KA, Martinez JM, Tichansky DS (2009) Intraoperative endoscopy and leaks after laparoscopic Roux-en-Y gastric bypass. Am Surg 75:485–488 (discussion 488)PubMed

25.

Alasfar F, Chand B (2010) Intraoperative endoscopy for laparoscopic Roux-en-Y gastric bypass: leak test and beyond. Surg Laparosc Endosc Percutan Tech 20:424–427CrossRefPubMed

26.

Madan AK, Stoecklein HH, Ternovits CA, Tichansky DS, Phillips JC (2007) Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass. Surg Endosc 21:194–196CrossRefPubMed

27.

Torrington KG, Bowman MA (1981) Fatal hydrothorax and empyema complicating a malpositioned nasogastric tube. Chest 79:240–242CrossRefPubMed

28.

Winterholler M, Erbguth FJ (2002) Accidental pneumothorax from a nasogastric tube in a patient with severe hemineglect: a case report. Arch Phys Med Rehabil 83:1173–1174CrossRefPubMed

29.

Causey MW, Fitzpatrick E, Carter P (2013) Pressure tolerance of newly constructed staple lines in sleeve gastrectomy and duodenal switch. Am J Surg 205:571–574 (discussion 574–575)CrossRefPubMed

30.

Sucandy I, Szomstein S, Rosenthal RJ (2010) Palmar staining following methylene blue leak test during laparoscopic Roux-en-Y gastric bypass. J Laparoendosc Adv Surg Tech A 20:563–564CrossRefPubMed

31.

Lee JH, Chang CH, Park CH, Kim JK (2014) Methylene blue dye-induced skin necrosis in immediate breast reconstruction: evaluation and management. Arch Plast Surg 41:258–263PubMedCentralCrossRefPubMed

Title: Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy
Authors: Monica Sethi
Jonathan Zagzag
Karan Patel
Melissa Magrath
Eduardo Somoza
Manish S. Parikh
John K. Saunders
Aku Ude-Welcome
Bradley F. Schwack
Marina S. Kurian
George A. Fielding
Christine J. Ren-Fielding
Publication date: 01-03-2016
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 3/2016
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-015-4286-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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