Gastrointestinal Leaks Research Articles

Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

Demography and Mortality of Body Packers; an Extended Experience from a Referral Center.

The incidence of smuggling and illegal transport of substances by internal concealment, also known as body packing, is increasing. The clinical approach to body packers has changed significantly over the past two decades. In addition, the mortality of body packers is an important issue in patient management. The purpose of the current study is to determine the statistics and mortality related to body packing. In this cross-sectional study, all body packer patients who referred to Loghman Hakim hospital were evaluated from 2010 to 2017. Demographic characteristics, findings of clinical imaging, treatment, and outcome of the patients were recorded. The data were analyzed using SPSS version 21. A total of 303 patients were enrolled in the study after the diagnosis of body packing by abdominal CT scanning without contrast. Conservative treatment including whole bowel irrigation (WBI) accompanied by close monitoring was done for 78% (n = 236) of patients; moreover, 26 patients (8.5%) underwent surgery after WBI, and 41 patients (13.5%) underwent surgery without bowel irrigation. Mortality was observed in eight patients (2.7%) five of whom (62.5%) died before surgery and had the clinical manifestation of crystal (methamphetamine) and cannabis toxicity. Furthermore, three patients (37.5%) died due to the complications of surgery such as gastrointestinal leakage of an abdominal abscess. Conservative treatment seems to be better for the management of body packers. In addition, it is necessary to monitor patients for possible signs and symptoms of intoxication and gastrointestinal obstruction.

Development and validation of machine learning models to predict gastrointestinal leak and venous thromboembolism after weight loss surgery: an analysis of the MBSAQIP database.

Postoperative gastrointestinal leak and venous thromboembolism (VTE) are devastating complications of bariatric surgery. The performance of currently available predictive models for these complications remains wanting, while machine learning has shown promise to improve on traditional modeling approaches. The purpose of this study was to compare the ability of two machine learning strategies, artificial neural networks (ANNs), and gradient boosting machines (XGBs) to conventional models using logistic regression (LR) in predicting leak and VTE after bariatric surgery. ANN, XGB, and LR prediction models for leak and VTE among adults undergoing initial elective weight loss surgery were trained and validated using preoperative data from 2015 to 2017 from Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Data were randomly split into training, validation, and testing populations. Model performance was measured by the area under the receiver operating characteristic curve (AUC) on the testing data for each model. The study cohort contained 436,807 patients. The incidences of leak and VTE were 0.70% and 0.46%. ANN (AUC 0.75, 95% CI 0.73-0.78) was the best-performing model for predicting leak, followed by XGB (AUC 0.70, 95% CI 0.68-0.72) and then LR (AUC 0.63, 95% CI 0.61-0.65, p < 0.001 for all comparisons). In detecting VTE, ANN, and XGB, LR achieved similar AUCs of 0.65 (95% CI 0.63-0.68), 0.67 (95% CI 0.64-0.70), and 0.64 (95% CI 0.61-0.66), respectively; the performance difference between XGB and LR was statistically significant (p = 0.001). ANN and XGB outperformed traditional LR in predicting leak. These results suggest that ML has the potential to improve risk stratification for bariatric surgery, especially as techniques to extract more granular data from medical records improve. Further studies investigating the merits of machine learning to improve patient selection and risk management in bariatric surgery are warranted.

Technical and Clinical Considerations for Successful Management of Postoperative Bowel Perforation by Percutaneous Foley Catheter Placement.

PurposeThe aim of this study was to analyze several technical and clinical factors associated with the successful management of postoperative leakage by percutaneous Foley catheter placement.Materials and MethodsThirty-two patients were included in this retrospective study. Postoperative gastrointestinal leakage was diagnosed by computed tomography (CT) and the patients underwent percutaneous Foley catheter placement into the leakage site through Jackson-Pratt tubes or imaging-guided methods. Clinical success was defined as successful Foley catheter removal without symptom recurrence within 1 week and the risk factors for clinical failure were analyzed.ResultsIn all patients, percutaneous Foley catheter placement was successfully achieved without complications. Foley catheter was placed at a median of 10 days (range, 1–68) after the confirmation of leakage on CT. Clinical success was achieved in 26 of the 32 patients (81%). Systemic comorbidity (p < 0.001) and failed oral intake (p = 0.015) were the statistically significant risk factors for clinical failure.ConclusionPercutaneous Foley catheter placement can be considered an effective approach for the management of postoperative bowel leakage. The presence of systemic comorbidity and successful oral diet after Foley catheter placement are significant factors for successful clinical recovery.

Research Note: Evaluation of a heat stress model to induce gastrointestinal leakage in broiler chickens

The purpose of this study was to evaluate heat stress as a model to induce gastrointestinal leakage in broiler chickens. On the day of hatch, 320 chicks were allocated into 8 environmental chambers, 4 thermoneutral (TN) and 4 continuous heat stress (HS). Each chamber was divided into 2 pens containing separate feeders and water jugs (8 replicates per treatment, 20 birds/pen). The environment was established to simulate production setting as best possible for the first 21 D. A gradual reduction of temperature from 32°C to 24°C with relative humidity at 55 ± 5% was adopted for the first 21 D. At the time of HS, the HS groups were exposed to 35°C from Day 21 to 42, while thermoneutral ones were maintained at 24°C from Day 21 to 42. Chickens were equipped with a Thermochron temperature logger for continuous monitoring of core body temperature. The environmental temperature and relative humidity were continuously recorded. Fluorescein isothiocyanate–dextran (FITC-d) was orally gavaged to 2 chickens/replicate (n = 16) randomly selected on days 21, 28, 35, and 42. After 1 h of oral gavage, blood samples were collected to determine the passage of FITC-d. Tibias were removed from all chickens to evaluate break strength only on 21 D and 42 D (before HS and at the end of the trial). Performance parameters were evaluated weekly from 21 D to the end of the trial. Body temperature was significantly (P < 0.05) increased after 2 h of starting HS and remained that way until the end of the study. Chronic HS caused an increase in core body temperature which decreased feed intake, body weight, and feed efficiency (28, 35, and 42 D) when compared with control TN chickens. Similarly, serum FITC-d was significantly increased in HS chickens at all points of evaluation. Chronic HS also caused a significant reduction of bone strength at 42 D when compared with the control chickens. The results from the present study suggest that HS can be a robust model to induce gut leakage in broiler chickens.

Prognostic indicators in cats with septic peritonitis (2002-2015): 83 cases.

To identify physical exam findings, clinicopathological parameters, time to surgery, empirical antimicrobial use, and culture results that could be associated with outcome in cats with septic peritonitis (SP). Retrospective cohort study of cats from 2002 to 2015. Four university teaching hospitals. Eighty-three cats diagnosed with SP by cytology or culture. None MEASUREMENTS AND MAIN RESULTS: Fifty-eight cats survived to discharge (69.9%); 1 cat was euthanized in surgery; 20 were euthanized postoperatively; 4 cats suffered cardiac arrest after surgery. The most common etiology of SP was secondary SP due to gastrointestinal perforation (49.4%), followed by primary SP (22.3%). Mean blood glucose concentration was significantly different between survivors and nonsurvivors (P=0.006). Cats that received appropriate empirical antibiotic therapy were 4.4 times more likely to survive than cats that did not receive appropriate antibiotics (P=0.018). As previously documented, SP secondary to gastrointestinal leakage was the most common etiology. In this population, cats with a higher blood glucose concentration on presentation had a worse prognosis. Cats that received appropriate empirical antimicrobial therapy were more likely to survive.

Efficacy and feasibility of OverStitch suturing of leaks in the upper gastrointestinal tract.

Management of upper gastrointestinal leaks is challenging. A new potential treatment option for this complication is endoscopic suturing with the OverStitch system (Apollo Endosurgery, Texas, USA), which is today mainly used for endoscopic sleeve gastroplasty. The aim of this study was to analyze the efficacy and feasibility of this new treatment option in patients with leaks in the upper gastrointestinal tract. We performed a retrospective, single-center study of all patients who underwent endoscopic suturing with OverStitch of leaks in the upper gastrointestinal tract. Endoscopic suturing was performed on 13 patients (mean age, 59.62 ± 16.29years; mean leak size, 22.31 ± 22.6mm) over a period of 8months. Postoperative leaks were detected in 10 patients (76.9%) after foregut surgery. Interventional success was achieved in all endoscopic attempts (n = 16, 100%) with a mean closure time of 28.0 ± 12.36min per patient. Follow-up technical success rate for each suture was (n = 8, 50.0%). Clinical success, including repeated suture attempts was achieved in 8 of the 13 patients (61.5%). These 8 patients had not received prior treatment for the leak. No immediate or delayed serious complications occurred as a result of OverStitch. The mean follow-up was 95 ± 91.07days. Endoscopic suturing with OverStitch for leaks in the upper gastrointestinal tract is feasible and effective in patients who have not received prior treatment. This minimally invasive technique seems to be a promising option especially for patients with large leaks and significant comorbidities.

2409 A Rare Complication of Gastric Bypass in the Setting of Chronic Liver Disease

INTRODUCTION: Porto-mesenteric venous thrombosis (PMVT) is a known and potentially fatal complication of general surgery. However, it has been rarely reported as a complication of worsening liver disease after undergoing bariatric surgery. This is a case of a patient who presented with mesenteric thrombosis following Roux-en-y gastric bypass (RYGB). CASE DESCRIPTION/METHODS: Patient is a 42-year-old African American female with a history of RYGB who presented with episodes of post-operative abdominal pain for 5 years. She was found to have recurrent high-grade small bowel obstruction's (SBO) necessitating a small bowel resection. Her course was further complicated by intra-abdominal abscesses requiring computed tomography (CT)-guided drainage, and wound dehiscence requiring open surgical intervention and debridement. Four months after discharge, she presented with right-sided abdominal pain and acute encephalopathy. Liver enzymes were elevated. Abdominal ultrasound revealed portal vein thrombosis (PVT). Dual-phase CT of the abdomen revealed sub-acute to chronic complete diffuse mesenteric thrombosis with collateralizations involving the portal, splenic, and distal superior mesenteric veins. Given that previous imaging suggested steatosis and hepatomegaly, sub-acute liver injury secondary to thrombosis was established in the setting of chronic liver disease. The patient's underlying non-alcoholic fatty liver disease was likely worsened by severe malnutrition and short gut syndrome following the RYGB. Her hepatic encephalopathy resolved after initiating lactulose and rifaximin. Outpatient hematology evaluation for all causes of thrombophilia remained inconclusive and the patient had no recurrences of thrombosis. DISCUSSION: RYGB remains the gold standard for bariatric surgery as it results in the most durable weight loss. However, complications may occur such as gastrointestinal leak, fistulas, marginal ulcers, SBO, and dumping syndrome. Mechanisms of thrombosis formation in this setting could be related to intra-operative vascular manipulation, increased intra-abdominal pressure, venous stasis, and possibly deteriorating liver function secondary to rapid weight loss and malnutrition. PMVT hasn't been reported consistently as a complication in various bariatric surgery studies, which leads us to conclude that it's either under or mis-diagnosed. It is extremely important to consider PMVT as a complication of RYGB in patients who have evidence of underlying liver disease prior to undergoing RYGB.

Endoluminal Vacuum Therapy: Changing the Management of Upper Gastrointestinal Leaks

Noorani, Ayesha MD, PhD; Anthony-Pillai, Aaron MD; Pournaras, Dimitrios MD, FRCS; Safranek, Peter M. MD, FRCS; Sujendran, Vijayendran S. MD, FRCS; Bennett, John M. MD, FRCS; Hardwick, Richard H. MD, FRCS; Gourgiotis, Stavros MD, PhD, FACS, FEBS, FRCS; Hindmarsh, Andrew MD, FRCS Author Information

Analysis of risk factors for digestive tract leakage after radical gastrectomy

Objective To explore the relationship between gastrointestinal leakage after perioperative radical gastrectomy and perioperative factors. Methods The clinical data of 602 patients who underwent radical gastrectomy for gastric cancer in Beijing Friendship Hospital, Capital Medical University from January 2013 to December 2017 were retrospectively analyzed, including 420 male case and 182 female cases. Patients with postoperative gastrointestinal leakage of univariate and multivariate Logistic regression analysis. Results Of the 602 patients who underwent radical gastrectomy, 44 (7.3%) had gastrointestinal leakage after operation, and the mean time was 9 (1 to 49) days. Univariate analysis showed that the incidence of digestive tract leakage after radical gastrectomy was age, body mass index(BMI)≥24.0 kg/m2, previous drinking history, hypoproteinemia ( 0.05). Multivariate logistic analysis showed that the history of combined drinking, BMI≥24.0 kg/m2, and the tumor site is based on the gastric body as the standard distal stomach, carcino-embryonic antigen, hypoproteinemia (<40 g/L) were relatively independent risk factors for digestive tract leakage after radical gastrectomy. Conclusions Age, BMI≥24.0 kg/m2, previous drinking history, hypoproteinemia (<40 g/L), carcino-embryonic antigen positive, CA19-9 positive, tumor site, combined organ resection, postoperative pathological type, postoperative T stage, postoperative N stage, postoperative M stage, postoperative TNM staging and other factors are risk factors for digestive tract leakage after radical gastrectomy, while previous drinking history, hypoproteinemia (<40 g/L), BMI (≥24.0 kg/m2), carcino-embryonic ontigen, tumor′s site is a relatively independent risk factor for digestive tract leakage after radical gastrectomy. Serum albumin and BMI levels need to be strictly controlled during the perioperative period, and the occurrence of postoperative digestive tract leakage is reduced in the case of effective alcohol withdrawal. Key words: Stomach neoplasms; Risk factors; Retrospective studies; Radical gastrectomy; Digestive tract leakage

The effect of moderate-dose aflatoxin B1 and Salmonella Enteritidis infection on intestinal permeability in broiler chickens.

The effect of dietary aflatoxin B1 (AFB1) and Salmonella Enteritidis infection on intestinal permeability was investigated. Two hundred 1-day-old male Ross 308 broiler chickens were randomly divided into 4 treatments of 5 replicates each (10 birds per replicate), which were fed ad libitum for 3weeks with the following treatments: control, chickens fed an AFB1-free diet; AF, chickens fed an AFB1-contaminated diet at 470ng/g; SE, chickens fed an AFB1-free diet and challenged with 108cfu of S. Enteritidis per bird at 18days old; AF + SE, chickens fed an AFB1-contaminated diet and challenged with 108cfu of S. Enteritidis per bird at 18days old. At day 21 of age, chicks received an oral gavage dose of fluorescein isothiocyanate dextran (FITC-dextran) to evaluate gastrointestinal leakage. Blood and intestinal samples were collected to evaluate serum biochemistry and total intestinal IgA secretion, respectively. Liver tissues were aseptically collected to assess bacterial invasiveness and for histomorphological studies. The results showed that chickens receiving AFB1 presented a significant increment (up to 2.4-fold) in serum FITC-dextran concentration (p < 0.05). Nevertheless, S. Enteritidis infection had no additional effect on gastrointestinal leakage. Furthermore, the ingestion of AFB1 had no impact on the invasive potential of S. Enteritidis. These results suggest that moderate-dose AFB1 adversely affects intestinal barrier function resulting in increased gut permeability in broiler chickens.

189 – Technical Success is the Sole Predictor of Successful Endoscopic Closure of Post-Surgical Gastrointestinal Leaks: A Multicenter North American Cohort

189 – Technical Success is the Sole Predictor of Successful Endoscopic Closure of Post-Surgical Gastrointestinal Leaks: A Multicenter North American Cohort

Predictors and outcomes of leak after Roux-en-Y gastric bypass: an analysis of the MBSAQIP data registry

BackgroundGastrointestinal leak is one of the most severe postoperative complications after Roux-en-Y gastric bypass (RYGB), occurring in up to 2% of all patients. This has led to adoption of simpler procedures, such as sleeve gastrectomy, which have improved safety profiles but potentially less effective long-term metabolic outcomes. Yet, in contrast to sleeve gastrectomy, a paucity of modern literature exists regarding predictors of leak for RYGB. ObjectivesThe purpose of this study was to examine gastrointestinal leak in patients undergoing RYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry. MethodsWe identified all Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent RYGB in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of leak in RYGB patients. Our secondary outcomes of interest include characterizing overall complication rates in RYGB patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ2 tests for categoric data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of leak. SettingAll centers belonging to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry. ResultsA total of 77,596 patients underwent RYGB from 2015 to 2016. The majority of patients were female (79.8%), white (75.9%), and underwent laparoscopic RYGB (89.7%). The mean age of patients was 45.2 years (standard deviation 11.9) with a mean body mass index of 46.3 kg/m2 (standard deviation 8.17). Complication rates for RYGB were low with a mortality of .16% and a total complication rate of 7.5%. A total of 476 leaks were identified with an overall leak rate of .6% and a mortality of 1.5%. Leak was associated with a statistically significant increase in all complications as well as readmission, reoperation, and mortality rates at 30 days. Multivariable logistic regression analysis revealed the following statistically significant independent predictors of leak: body mass index, age, operative length, American Society of Anesthesiologists score >3, prior pulmonary embolus, and partially dependent functional status. Albumin was the only independent protective variable after adjusting for confounders and interactions. ConclusionUsing the robust Metabolic and Bariatric Surgery Accreditation and Quality Improvement database, we found RYGB to be a safe procedure with low morbidity and mortality. The overall leak rate was .6% with leak significantly increasing all other complications, readmission, reoperation, and mortality rates at 30 days. Logistic regression identified prior pulmonary embolus and partially dependent functional status as the 2 largest predictors of leak while increased albumin was the only protective factor. Optimizing preoperative nutrition and strength in these patients through structured multidisciplinary programs may therefore have a role in the ongoing improvement of outcomes after RYGB.

Endoscopic Management of Postbariatric Fistulae and Leaks

The number of bariatric procedures performed annually is increasing along with the number of complications. Gastrointestinal leak after bariatric surgery generally portends high morbidity and mortality, and its management depends on clinical and radiographic presentation. A leak is defined as an enteric defect with extravasation of luminal contents. Fistulae are abnormal connections between two epithelialized surfaces, are usually chronic, and may develop from long-standing leaks. Endoscopic therapies may offer an attenuated risk profile compared with surgical intervention and play a growing role in the management of postbariatric complications. Leak resolution may require multiple endoscopic sessions and modalities (e.g., stents, adhesives, plugs, clips, suturing, and VAC-assisted closure); therefore, it is critical to have appropriate follow-up and surveillance after therapeutic endoscopic intervention. This review discusses endoscopic leak and fistula management through endoscopic procedures, addressing indications and candidates for procedure, contraindications, recipient evaluation, and aspects of procedure, including proper timing, equipment, and types. Figures show Roux-en-Y gastric bypass, sleeve gastrectomy, management options for leaks after bariatric surgery, a diagnostic algorithm for leaks, upper gastrointestinal series performed with Gastrografin, and computed tomographic scans that demonstrate extraluminal air extending along the diaphragmatic surface of the spleen and a perisplenic gas and fluid-filled collection on the lateral margin. Tables list complications that follow bariatric surgery; an excerpt from the 2008 American Society for Gastrointestinal Endoscopy Guidelines; recommended equipment for endoscopic defect management; classification system based on duration after bariatric surgery; classification and approach to management based on clinical presentation and radiographic findings; summary of recommendations for pre-endoscopy, index endoscopy, therapeutic endoscopy, and posttherapeutic endoscopy; and early and late complications of stent placement. This review contains 7 highly rendered figures, 7 tables, and 104 references.

Randomized controlled trial of monopolar cautery versus clips for staple line bleeding control in Roux-en-Y gastric bypass

BackgroundBleeding from the staple line is a rare but serious problem following bariatric surgery. Staple line bleeding control (SLBC) can be achieved in different ways such as the application of sutures, clips, glue or buttressing materials over the staple line. Cauterization alone is generally not preferred due to concerns about debilitating the staple line. ObjectivesThe aim of this study was to compare the clip and monopolar cauterization methods for SLBC in laparoscopic Roux-en-Y gastric bypass. SettingUniversity hospital. MethodsA total of 70 morbidly obese patients were randomized into two groups. Patients with previous upper gastrointestinal surgery, re-do procedures and open surgeries were excluded. Their demographic characteristics, intraoperative and postoperative outcomes were examined. ResultsA total of 489 SLBC interventions (274 clips and 215 cauterizations) were performed after 280 stapling applications. SLBC intervention number and location, additional trocar requirement, blood loss and operation time were not different between the groups. In the clip group, two patients required monopolar cauterization when clipping failed. No intraabdominal bleeding or gastrointestinal leakage was seen in any group. Postoperative gastrointestinal hemorrhage was seen in three patients, two in the clip group and one in the cautery group. There was no difference between the groups in terms of postoperative pain score, abdominal drainage amount, hemoglobin level alteration, morbidity or length of stay. ConclusionsIn laparoscopic Roux-en-Y gastric bypass, monopolar cauterization for SLBC can be used instead of clipping. It appears that monopolar cautery is a safe and effective approach for SLBC in laparoscopic Roux-en-Y gastric bypass.

Open-pore film drainage (OFD): a new multipurpose tool for endoscopic negative pressure therapy (ENPT)

Background and study aims Endoscopic negative pressure therapy (ENPT) has been developed to treat gastrointestinal leakages. Up to now, ENPT has usually been performed with open-pore polyurethane foam drains (OPD). A big disadvantage of the OPDs is their large diameter. We have developed a new, small-bore open-pore film drainage (OFD). Herein we report our first experience in a case series of 16 patients. Patients and methods OFD is constructed with a drainage tube and a very thin double-layered open-pore drainage film (Suprasorb CNP, Drainage Film, Lohmann & Rauscher International, Germany). The distal end of the tube is wrapped with only one layer of film. OFD is placed into the gastrointestinal leakage site with common endoscopic techniques. The tube is connected to an electronic vacuum device and continuous negative pressure of –125 mmHg applied. Results From 2013 to 2016, 16 patients were treated with the new OFD device. In 10 patients, transmural intestinal defects (4 esophageal, 4 rectum/colon, 1 duodenal, 1 pancreatic cyst) were closed with ENPT in median time of 12 days (range 3 – 34 days). Five of the 10 patients were treated solely with OFD devices. In five patients ENPT started with ODP and changed to OFD when the cavity was shrunken to a channel with a small opening. In four patients postoperative gastric reflux was eliminated for 5 to 16 days. Conclusions Small-bore OFD opens up promising new treatment options within ENPT. OFD can be used in endoscopic closure management of intestinal leakages in the upper and lower gastrointestinal tract. Gastric reflux can be eliminated in an active manner. OFD can be inserted nasally. OFD may be an adequate substitute for OPD, especially when placement of the larger OPD is difficult.

Complete abdominal wound and anastomotic leak with diffuse peritonitis closure achieved by an abdominal vacuum sealing drainage in a critical ill patient: a case report

BackgroundNegative pressure wound therapy (NPWT) is a widely accepted technique to treat local infectious wounds of the skin, subcutaneous tissue, fascia, or muscle. Recently, several reports describing the efficacy of NPWT for various types of fistulas and anastomotic leaks have been published. We herein describe a patient with an open abdominal wound due to colonic anastomotic leakage and diffuse peritonitis, in whom abdominal vacuum sealing (AVS) as a modified NPWT was useful for the management of this complex wound.Case presentationA 32-year-old man was admitted to our hospital with late presenting traumatic diaphragmatic hernia and strangulated ileum complicated by necrosis of the ileum and transverse colon. He had a history of cervical spinal cord injury due to suicide attempt 14 years earlier and, as a result of cervical spinal cord injury, he was paralyzed in the lower body. The patient underwent an urgent hernia repair and bowel resection. Postoperatively, he developed severe septic shock. On postoperative day (POD) 6, wound dehiscence due to colonic anastomotic leakage with diffuse peritonitis was diagnosed, but he was unable to undergo re-operation because of refractory severe septic shock combined with neurogenic shock due to the cervical cord injury. The patient was treated with AVS therapy. He gradually recovered from septic shock, and the anastomotic leakage healed after a 2-month period. The wound dehiscence was also reduced. The patient resumed oral intake on POD 112 and was discharged on POD 190.ConclusionsAlthough surgical repair would be the best method for the treatment of diffuse peritonitis due to gastrointestinal perforation or anastomotic leakage, our case suggests that AVS with ‘conventional’ drainage is a treatment of choice for open abdominal wounds even in the presence of diffuse peritonitis caused by intestinal anastomotic leakage, especially in patients with poor general medical condition.

Risk Factors for Gastrointestinal Leak after Bariatric Surgery: MBASQIP Analysis

Gastrointestinal leak remains one of the most dreaded complications in bariatric surgery. We aimed to evaluate risk factors and the impact of common perioperative interventions on the development of leak in patients who underwent laparoscopic bariatric surgery. Using the 2015 database of accredited centers, data were analyzed for patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (LRYGB). Emergent, revisional, and converted cases were excluded. Multivariate logistic regression was used to analyze risk factors for leak, including provocative testing of anastomosis, surgical drain placement, and use of postoperative swallow study. Data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (n= 92,495 [69.3%]) and LRYGB (n= 40,983 [30.7%]) were analyzed. Overall leak rate was 0.7% (938 of 133,478). Factors associated with increased risk for leak were oxygen dependency (adjusted odds ratio [AOR] 1.97), hypoalbuminemia (AOR 1.66), sleep apnea (AOR 1.52), hypertension (AOR 1.36), and diabetes (AOR 1.18). Compared with LRYGB, laparoscopic sleeve gastrectomy was associated with a lower risk of leak (AOR 0.52; 95% CI 0.44 to 0.61; p < 0.01). Intraoperative provocative test was performed in 81.9% of cases and the leak rate was higher in patients with vs without a provocative test (0.8% vs 0.4%, respectively; p < 0.01). A surgical drain was placed in 24.5% of cases and the leak rate was higher in patients with vs without a surgical drain placed (1.6% vs 0.4%, respectively; p < 0.01). A swallow study was performed in 41% of cases and the leak rate was similar between patients with vs without swallow study (0.7% vs 0.7%; p= 0.50). The overall rate of gastrointestinal leak in bariatric surgery is low. Certain preoperative factors, procedural type (LRYGB), and interventions (intraoperative provocative test and surgical drain placement) were associated with a higher risk for leaks.

Preventing Rescue Surgeries by Endoscopic Clipping: A Valuable Resource in the Surgeon's Toolbox.

Over-the-scope-clip (OTSC) System is a relatively new endoluminal intervention for gastrointestinal (GI) leaks, fistulas, and bleeding. Here, we present a single center experience with the device over the course of 4 years. Retrospective chart review was conducted for patients who received endoscopic OTSC treatment. Primary outcome is the resolution of the original indication for clip placement. Secondary outcomes are complications and time to resolution. Forty-one patients underwent treatment with the OTSC system from 2011 to 2015 with average follow-up of 152 days. The average age is 53.7. The most common site of clip placement was in the stomach (44%). Clips were placed after surgical complication for 28 patients (68%), endoscopic complications for 8 patients (19%), and spontaneous presentation in 5 patients (12%). Technical success was achieved in all patients. Overall, 34 patients (83%) were successfully treated. Nine patients required multiple clips and three patients required additional treatment modalities after OTSC. Four patients used the OTSC as a bridging therapy to surgery. Using OTSC for palliation versus nonpalliative indications was associated with lower rates of treatment success (50% versus 86%, P = .028). Using OTSC for symptoms <6 months had higher rates of treatment success than those experiencing longer symptoms (88% versus 65%, P = .045). There were no major morbidities or mortalities directly associated with the OTSC system. Complications from clip use were pain in two patients (5%) and hematemesis in one patient (3%). The OTSC System can be a very successful treatment for iatrogenic or spontaneous GI leaks and bleeds. Treatment success is more likely in patients treated within 6 months of diagnosis and less likely to when used for palliation. It was also successfully used as bridging therapy in several patients.

Endoluminal Vacuum Therapy (E-Vac): A Treatment Option in Oesophagogastric Surgery

BackgroundLeaks from the upper gastrointestinal tract often pose a management challenge, particularly when surgical treatment has failed or is impossible. Vacuum therapy has revolutionised the treatment of wounds, and its role in enabling and accelerating healing is now explored in oesophagogastric surgery.MethodsA piece of open cell foam is sutured around the distal end of a nasogastric tube using a silk suture. Under general anaesthetic, the foam covered tip is placed endoscopically through the perforation and into any extra-luminal cavity. Continuous negative pressure (125 mmHg) is then applied. Re-evaluation with change of the negative pressure system is performed every 48–72 h depending on the clinical condition. Patients are fed enterally and treated with broad-spectrum antibiotics and anti-fungal medication until healing, assessed endoscopically and/or radiologically, is complete.ResultsSince April 2011, twenty one patients have been treated. The cause of the leak was postoperative/iatrogenic complications (14 patients) and ischaemic/spontaneous perforation (seven patients). Twenty patients (95%) completed treatment successfully with healing of the defect and/or resolution of the cavity and were subsequently discharged from our care. One patient died from sepsis related to an oesophageal leak after withdrawing consent for further intervention following a single endoluminal vacuum (E-Vac) treatment. In addition, two patients who were successfully treated with E-Vac for their leak subsequently died within 90 days of E-Vac treatment from complications that were not associated with the E-Vac procedure. In two patients, E-Vac treatment was complicated by bleeding. The median number of E-Vac changes was 7 (range 3–12), and the median length of hospital stay was 35 days (range 23–152).ConclusionsE-Vac therapy is a safe and effective treatment for upper gastrointestinal leaks and should be considered alongside more established therapies. Further research is now needed to understand the mechanism of action and to improve the ease with which E-Vac therapy can be delivered.