Intraoperative Leak Research Articles

Endocranial Complications of Endoscopic Sinus Surgery: Learning from Experience

Objectives: We critically reviewed our experiences in endocranial complications with Functional Endoscopic Sinus Surgery, and investigated the causes, prevention strategies and management. Methods: We conducted a retrospective study of endocranial complications with Functional Endoscopic Sinus Surgery performed during last 10 years in our ENT department. We analyzed endocranial complications, their causes, consequences, treatments and outcomes. Management was performed in collaboration with neurosurgeons and infectious diseases specialists. Results: Of 763 Functional Endoscopic Sinus Surgery procedures, we identified three cases with endocranial complications (0.393%). These complications included: a case of postoperative severe cerebrospinal fluid leak in a patient treated for severe polyposis; a case of cerebral-frontal abscess with delayed clinical manifestation (4 weeks post-surgery) in a patient treated for chronic pansinusitis who experienced difficult surgery for septal spur; and a case of pneumocephalus in a patient treated for allergic fungal sinusitis. The clinical outcome was favorable in all cases. Conclusions: Intra-operative cerebrospinal fluid leak, anatomical deformities (even minimal deformities) and massive inflammatory sinus disease are predisposing factors for endocranial complications with Functional Endoscopic Sinus Surgery. Prognosis can be favorable when therapeutic management is carried out in collaboration with neurosurgeons and infectious disease specialists.

Application of bio-mesh-reinforced pancreatico-gastrostomy after pancreaticoduodenectomy

To evaluate the clinical efficacy of bio-mesh-reinforced pancreaticogastrostomy. A total of 23 patients undergoing bio-mesh-reinforced pancreaticogastrostomy from May 2011 to January 2013 were retrospectively analyzed. Their demographic data, operative parameters and post-operative outcomes were recorded. The severity of pancreatic leak was determined according to the criteria of International Study Group on Pancreatic Fistula (ISGPF). The mean anastomotic time was 24 (20-35) minutes. Intra-operative leak tests showed all pancreatic anastomoses were watertight. Six patients (26.1%) had pancreatic leakage of grade A. One patient (4.3%) had pancreatic leakage of grade B. No patient developed postoperative pancreatic leakage of class C. One case of abdominal infection was reported. No severe complications such as hemorrhage, bile leakage or gastrojejunostomy leakage were observed. All patients recovered well within Month 1 post-discharge. This novel technique may be a simple and feasible strategy for all types of pancreatic remnants.

Treatment of intraoperative nasal cerebrospinal fluid leak of patients with hormone active pituitary adenomas

Intraoperative nasal cerebrospinal fluid leak are common during the transnasal transsphenoidal interven tions. In certain cases, it is a feature of these interventions. However, its amplification needs a mandatory treatment. In this article, we describe the technique for closure dural defects that have developed during the transnasal removal of hormone active pituitary adenomas, using thrombin and fibrinogen containing colla genic sponge.

Re: What I do if things go wrong: up-to-date expert opinion referencing the best evidence available on intraoperative cerebrospinal fluid leak during endoscopic sinus surgery

Re: What I do if things go wrong: up-to-date expert opinion referencing the best evidence available on intraoperative cerebrospinal fluid leak during endoscopic sinus surgery

The use of the nasoseptal flap to reduce the rate of post-operative cerebrospinal fluid leaks following endoscopic trans-sphenoidal surgery for pituitary disease

Introduction. Our aim was to evaluate the routine use of a pedicled nasoseptal flap (NSF) as a primary repair for intra-operative CSF leaks compared with fat/fascia lata graft and lumbar drain insertion by performing a retrospective review of elective patients undergoing primary trans-sphenoidal surgery from January 2008 to present. Materials and methods. A retrospective review of consecutive primary elective trans-sphenoidal cases for sellar pathology was undertaken. Prior to September 2009, microscopic trans-sphenoidal surgery (MTSS) was performed in 40 cases and since then endoscopic trans-sphenoidal surgery (ETSS) was performed in 100 cases. Results and analysis. In the MTSS group, intra-operative CSF leaks were repaired with fat graft, tisseal and lumbar drain insertion. Intra-operative leaks in the ETSS group were routinely repaired with a pedicled NSF. Post-operative CSF leak rates were 12.5% in the MTSS and 3% in the ETSS groups, respectively. Three patients in the ETSS group developed a post-op CSF leak. All of these patients underwent surgery for craniopharyngiomas. This group had subsequent endoscopic repairs and were managed with repositioning of the NSF. Conclusion. The advent of the pedicled NSF conveys a significant advantage in preventing post-operative CSF leak, decreasing the morbidity associated with lumbar drain insertion and reduces the length of hospital stay.

Pressure tolerance of newly constructed staple lines in sleeve gastrectomy and duodenal switch

BackgroundMany bariatric surgeons elect to pressure test the newly constructed staple lines in sleeve gastrectomy and duodenal switch procedures as a means of intraoperatively detecting leaks. The pressure tolerance of these fresh staple lines has not been well studied in a clinical setting. MethodsThis is a retrospective institutional review board–approved study that analyzed resected stomachs immediately after resection during a bariatric operation performed using sleeve gastrectomy or biliopancreatic diversion with duodenal switch. Resected stomachs were connected to a normal saline infusion and manometric pressure device for determining the maximum stomach capacity, the leak pressure, and the location of the first leak. ResultsThirty patients (9 underwent biliopancreatic diversion with duodenal switch and 21 underwent sleeve gastrectomy) met the inclusion criteria (mean age of 44.7 years, 63.3% female) with a mean body mass index of 44.1 that was higher with biliopancreatic diversion (51.3 vs 41.0, P = .001) and a mean weight loss of 83 lb (a body mass index decrease of 13.4; median follow-up, 307 days). The leak volume of the resected stomach averaged 1,478 mL (range 1,100 to 2,200) with an average pressure of 25.6 cm H2O (range 12 to 60). The volume and leak pressures were equivalent despite the operative approach (P = .79 and .32, respectively), and there was no difference in the location of the leak (staple line or intrinsic stomach) based on volume or pressure (P = .246 and .131, respectively), with 50% of leaks occurring on the staple lines. ConclusionsThe fresh staple lines in vertical sleeve gastrectomy and duodenal switch show burst strength well in excess of any intragastric pressures likely to be created by brief intraoperative leak checks via air instilled by an orogastric tube or intraoperative endoscopy. Leak testing is not likely to create iatrogenic damage to properly constructed fresh staple lines in these procedures.

Pseudocapsular Removal of Pituitary Tumors Lowers Incidence of Intraoperative Cerebrospinal Fluid Leak

Pseudocapsular Removal of Pituitary Tumors Lowers Incidence of Intraoperative Cerebrospinal Fluid Leak

Laparoscopic Sleeve Gastrectomy with Tri-Staple™ Reinforcement for Severe Obesity

Background: Obesity is a chronic disease that affects over 500 million adults globally. Bariatric surgery is the only evidence-based treatment to achieve sustainable weight loss. Laparoscopic Sleeve Gastrectomy (LSG) is a restrictive procedure with important physiologic changes. Staple line dehiscence and hemorrhage represent two of the major complications associated with this procedure. Respectively, surgeons have attempted numerous modalities to avert these issues by using various stapling products, buttresses and hemostatic adjuncts. The purpose of this study is to analyze the utility of a Tri-staple non-buttressed stapler on the incidence of postoperative leakage and hemorrhage post LSG. Methods: A retrospective review of medical records was performed for 97 consecutive patients that underwent LSG with the Tri-Staple™ between July 2011 and October 2012. Results: The mean age of patients was 44.4 ± 9.2 years, with mean preoperative BMI of 48.5±10.6kg/m2. Preoperative comorbidities included Type 2 diabetes (34%), hypertension (42%), dyslipidemia (28%), and obstructive sleep apnea (43%). The mean operative time was 80.0 ± 22.0min. There were no intraoperative leaks identified. There were no documented postoperative leaks or bleeds after a median follow up of 12 months. At 12 months following surgery, BMI had significantly decreased to 33.9 ± 6.6 kg/m2 (p<0.05), corresponding to a EWL% of 54.8% ± 24.2%. HbA1c was significantly reduced after 1 year (6.7 ± 1.2 vs 5.6 ± 0.7, P<0.05). Conclusion: The Tri-Staple™ configuration used in LSG seems to mitigate staple line failures. Furthermore, weight loss and co morbidity reduction was determined to be acceptable and equivalent to LSG using other staplers

Can technical factors explain the volume-outcome relationship in gastric bypass surgery?

BackgroundThe existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship. ObjectiveThe purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS. MethodsLABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors. ResultsHigh-volume surgeons (>100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (<25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone. ConclusionHigh-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved.

Intraoperative anastomotic dye test significantly decreases incidence of anastomotic leaks in patients undergoing resection for rectal cancer

Anastomotic leakage is still a major complication in colorectal surgery. Prompt recognition and immediate treatment of anastomotic leak during surgery may reduce postoperative morbidity and mortality. Various types of intraoperative anastomotic test have been proposed to reduce the incidence of this complication. The aim of this study was to assess our experience with intraoperative dye test in rectal cancer surgery. Between 2006 and 2009, a retrospective review of a single general surgeon's practice identified 76 patients who underwent the intraoperative dye test in rectal cancer surgery. Seventy-three of these 76 patients underwent elective surgery without creation of a diverting stoma. Diluted dye was routinely introduced into the rectal lumen to test anastomotic integrity. Intraoperative leak was repaired prior to the completion of the procedure. No routine radiological survey assessed anastomotic integrity postoperatively. In 11 (14.5 %) out of 76 patients, anastomotic leaks were found and treated intraoperatively. None of the 65 patients without intraoperative leaks developed clinical leaks during the follow-up period. Postoperative leakage only occurred in one patient (1.3 %). He developed pelvic abscess evidenced by abdominal computed tomography scan and was treated non-operatively. The favorable results allow the authors to recommend the routine use of the intraoperative dye test for colorectal anastomoses.

Role of Intraoperative Esophagogastroenteroscopy in Minimizing Gastrojejunostomy-Related Morbidity: Experience with 2,311 Laparoscopic Gastric Bypasses with Linear Stapler Anastomosis

BackgroundAnastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital.MethodsMedical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals’ bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed.ResultsEndoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity.ConclusionsThe routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %).

Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients

Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. Among the 2,834 patients who underwent LSG, 44 (1.5%) with gastric leaks were identified. Of these 44 patients, 30 (68%) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m(2). Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3%) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20%), intermediately (3-14 days) in 32 cases (73%), and late (>14 days) in three cases (7%). For 38 patients (86%), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84%), 11 (50%), and 9 (60%) of these patients. Reoperation was performed for 27 of the patients (61%). Other treatment methods included percutaneous drainage (n = 28, 63.6%), endoscopic placement of stents (n = 11, 25%), clips (n = 1, 2.3%), and fibrin glue (n = 1, 2.3%). In 33 of the patients (75%), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14% (4/2,834). Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.

Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas

Cerebrospinal fluid leakage is a major complication of transsphenoidal surgery. An intraoperative CSF leak, which occurs in up to 50% of pituitary tumor cases, is the only modifiable risk factor for postoperative leaks. Although several techniques have been described for surgical repair when an intraoperative leak is noted, none has been proposed to prevent an intraoperative CSF leak. The authors postulated that intraoperative CSF drainage would diminish tension on the arachnoid, decrease the rate of intraoperative CSF leakage during surgery for larger tumors, and reduce the need for surgical repair of CSF leaks. The results of 114 transsphenoidal operations for pituitary macroadenoma performed without intraoperative CSF drainage were compared with the findings from 44 cases in which a lumbar subarachnoid catheter was placed before surgery to drain CSF at the time of dural exposure and tumor removal. Cerebrospinal fluid drainage reduced the rate of intraoperative CSF leakage from 41% to 5% (p < 0.001). This reduction occurred in macroadenomas with (from 57% to 5%, p < 0.001) and those without suprasellar extension (from 29% to 0%, p = 0.31). The rate of postoperative CSF leakage was similar (5% vs 5%), despite the fact that intraoperative CSF drainage reduced the need for operative repair (from 32% to 5%, p < 0.001). There were no significant catheter-related complications. Cerebrospinal fluid drainage during transsphenoidal surgery for macroadenomas reduces the rate of intraoperative CSF leaks. This preventative measure obviated the need for surgical repair of intraoperative CSF leaks using autologous fat graft placement, other operative techniques, postoperative lumbar drainage, and/or reoperation in most patients and is associated with minimal risks.

A prospective randomized trial to assess the effectiveness of Coseal to seal air leaks in lung surgery

We read with great interest the article by Tan et al .[ 1] assessing the efficacy of the Coseal surgical sealant in the treatment of air leaks after lung surgery, and we congratulate the authors for the scientific quality of their study. The results of this paper are conflicting with those reported in our recent randomized trial [2, 3], since they do not report any benefit in intra- and postoperative air leak control related to the use of the sealant, although the design of the two studies appears to be similar at first glance. As pointed out by the authors, there are two main differences in the methods of our study that potentially might have had an impact on results. They include: (i) the use of bovine pericardial strip reinforcement of the staplers employed for division of incomplete fissures and (ii) the exclusion of patients with mild (Grade 1) intraoperative air leaks. Since mild air leaks usually have a rapid spontaneous resolution, the inclusion in each study group of the trial by Tan, of more than 40% of patients presenting Grade 1 air leaks, may represent a factor influencing the results that could justify some differences with our study. Our trial has been performed on a statistical sample of >100 patients with moderate/severe air leaks for each group, while only 33–34 patients for each group in the English trial presented moderate or severe air leaks. Based on this data, it could be hypothesized that the benefit related to the application of the sealant is more likely in patients with higher severity of air leaks, in which a rapid spontaneous resolution is harder to be obtained. A further comment has to be said concerning the dose of product applied in each patient. In the English trial, no additional application over the standard dose (4 ml) has been reported after the first submersion test. In our study, some patients in the Coseal group received a double volume of sealant due to the presence of large sites of air leaks to be treated. In our previous experience with the sealant, we have observed that, in cases with multiple air leak sites treated with the division of the standard quantity of sealant in smaller doses for each parenchymal area, reappearance of air leak after initial postoperative evidence of air tightness may occur. This finding may suggest the need for an increase of the sealant dose when larger or multiple sites of air leaks are present. This aspect could have an impact on the results and, in our opinion, should be taken into account when assessing the efficacy of the sealant.

Reply to D'Andrilli and Rendina

(i) The exclusion of patients with mild (grade 1) intraoperative air leak. We included all patients with air leaks in our study as we did not want to make any assumptions about the length of time it would take for air leaks to resolve, whatever the grade of air leak. We allocated our patients into the two groups by minimization which ensured balance between the groups with respect to air leak grades among other factors [4]. Although it may appear that we had a smaller proportion of patients with moderate/severe air leaks (Grades 2/3), further inspection of the definition of air leak grades in fact indicate a likely cross-over in our grading system. D’Andrilli et al. graded mild as ‘countable bubbles’ and moderate as ‘a stream of bubbles’. In our grading system, Grade 1 was defined as ‘a single stream of bubbles’ and Grade 2 ‘multiple (2–5) but discrete bubble streams’. We considered it possible to count the number of streams which equates to the number of sources. It is likely that a substantial proportion of patients graded as 1 in our study would have been included in the Italian study as ‘moderate’ according to their grading criteria. However, the grading of air leak is extremely subjective and inter-observer variation is inevitable. It would be impossible to conclude with certainty if this has in fact contributed to the difference in results in the two trials. (ii) Dose of product applied in each patient. We would like to confirm as stated in our study, that patients in the CoSeal group did in fact receive an additional application of CoSeal if there was a persistent air leak after the first application, and often meant using a double volume of sealant similar to the Italian study. The air tightness test was performed for a third time after the second application, but no further CoSeal was applied if an air leak persisted at this stage.

Technical Controversies in Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, many bariatric surgeons have adopted it in recent years with good results. However, there is still no standard procedure across different surgical teams. We will discuss the more controversial aspects of the surgical technique: the size of the bougie, the beginning of the distal section, the section shape at the gastroesophageal junction, the necessity and manner of reinforcing the staple line, and the routine use of intraoperative leak testing.

Laparoscopic Reinforced Sleeve Gastrectomy: Early Results and Complications

Sleeve gastrectomy (SG) was pioneered as a two-stage intervention for super and super-super obesity to minimize morbidity and mortality; it is employed increasingly as a primary procedure. Early outcomes and integrity of laparoscopic SG (LSG) against leak using a technique incorporating gastric transection-line reinforcement were studied. Between 2003 and 2009, 121 patients underwent LSG (16, two-stage; 105, primary). Of the patients, 66% were women, mean age 38.8 ± 10.9 (15.0-64.0), and body mass index (BMI, kg/m(2)) 48.7 ± 9.3 (33.7-74.8). Bovine pericardium (Peri-Strips Dry [PSD]) was used to reinforce the staple line. Parametric and nonparametric tests were used, as appropriate. The paired t test was used to assess change from baseline; bivariate analyses and logistic regression were used to identify preoperative patient characteristics predictive of suboptimal weight loss. Mean operative time was 105min (95-180), and mean hospitalization was 5.6days (1-14). There was no mortality. There were 6 (5.0%) complications: 1 intraoperative leak, 1 stricture, 1 trocar-site bleed, 1 renal failure, and 2 wound infections. There were no postoperative staple-line leaks. Following 15 concomitant hiatal hernia operations, 3 (20%) recurred: 1 revised to RYGB and 2 in standby. Two post-LSG hiatal hernias of the two-stage series required revisions because of symptoms. BMI decreased 24.7% at 6months (n = 55) to 37.5 ± 9.3 (22.2-58.1); %EWL was 48.1 ± 19.3 (15.5-98.9). Twelve-month BMI (n = 41) was 38.4 ± 10.5 (19.3-62.3); %EWL was 51.7 ± 25.0 (8.9-123.3). Forty-eight-month BMI (n = 13) was 35.6 ± 6.8 (24.9-47.5); %EWL was 61.1 ± 12.2 (43.9-82.1) (p < 0.001). Preoperative BMI was predictive of >70% of patients who experienced <50% EWL at 6months. At 2weeks, 100% of type 2 diabetes patients (n = 23) were off medication (mean HbA(1C), 5.9 ± 0.5%; glycemia, 90.0 ± 19.9mg/dL (p < 0.01) at 3months). Laparoscopic PSD-reinforced LSG as a staged or definitive procedure is safe and effective in the short term and provides rapid type 2 diabetes mellitus reduction with a very low rate of complications.

Practice of routine intraoperative leak test during laparoscopic sleeve gastrectomy should not be discarded

Laparoscopic sleeve gastrectomy has become a popular procedure for the surgical management of morbid obesity [ 1 Aggarwal S. Kini S.U. Herron D.M. Laparoscopic sleeve gastrectomy for morbid obesity: a review. Surg Obes Relat Dis. 2007; 3: 189-194 Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar , 2 Márquez M.F. Ayza M.F. Lozano R.B. Morales-Mdel M. Díez J.M. Poujoulet R.B. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010; 20: 1306-1311 Crossref PubMed Scopus (116) Google Scholar ]. However, postoperative gastric leak after this procedure is a serious complication. The reported incidence of leak has varied from 0% to 5% [ 2 Márquez M.F. Ayza M.F. Lozano R.B. Morales-Mdel M. Díez J.M. Poujoulet R.B. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010; 20: 1306-1311 Crossref PubMed Scopus (116) Google Scholar , 3 Bellanger D.E. Greenway F.L. Laparoscopic sleeve gastrectomy, 529 cases without a leak—short term results and technical considerations. Obes Surg. 2011; 21: 146-150 Crossref PubMed Scopus (128) Google Scholar , 4 Burgos A.M. Braghetto I. Csendes A. et al. Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg. 2009; 19: 1672-1677 Crossref PubMed Scopus (193) Google Scholar , 5 Casella G. Soricelli E. Rizzello M. et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg. 2009; 19: 821-826 Crossref PubMed Scopus (168) Google Scholar , 6 Tan J.T. Kariyawasam S. Wijeratne T. Chandraratna H.S. Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg. 2010; 20: 403-409 Crossref PubMed Scopus (114) Google Scholar ]. The leak usually occurs through the upper part of the staple line near the gastroesophageal junction [ [4] Burgos A.M. Braghetto I. Csendes A. et al. Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg. 2009; 19: 1672-1677 Crossref PubMed Scopus (193) Google Scholar ]. It is a source of major morbidity and can be fatal. Intraoperative tests such as the methylene blue dye test, air leak test and endoscopy are used variably to diagnose staple line disruption. These tests are important when their findings are positive. A negative test, however, does not eliminate the possibility of leak in the postoperative period [ [5] Casella G. Soricelli E. Rizzello M. et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg. 2009; 19: 821-826 Crossref PubMed Scopus (168) Google Scholar ]. Hence, the routine practice of intraoperative leak test is widely debated.

Intraoperative Endoscopy for Laparoscopic Roux-en-Y Gastric Bypass

The aim of this study is to determine the role of intraoperative endoscopy in identifying gastrojejunostomy leak in laparoscopic Roux-en-Y gastric bypass (LRNYGB) and to define other roles that can be achieved by this diagnostic maneuver. A retrospective chart review of all patients who underwent LRNYGB at both Cleveland Clinic (USA) and Adan Hospital (Kuwait) was undertaken. All operations were performed by 2 surgeons (B.C. and F.A.).We analyzed the following parameters in the patients: mean age, estimated blood loss, average hospital stay, the number of patients who had intraoperative leaks, and those who developed intraoperative pouch bleeding. Between July 2004 and January 2009, 290 patients (244 women-85% and 46 men-15%) were operated upon with a mean age of 42 years (range: 19 to 61 y). The average body mass index was 48 kg/m2 (range: 35 to 65 kg/m2), and the average American Society of Anesthesiology classification of 3 (range: 2 to 4). Mean estimated blood loss of 95 mL (range: 27 to 310 mL) and the mean operative time was 165 minutes (range: 102 to 348 min). The average hospital stay was 3 days (range: 2 to 13 d). Eleven patients (3.7%) developed intraoperative leaks that were controlled intraoperatively. Ten patients (3.4%) developed intraoperative pouch bleeding, in 6 of them the bleeding vessel was controlled laparascopically. No documented postoperative leak in this series of patients. One patient (0.34%) underwent diagnostic laparoscopy for clinical suspicion of a leak which could not be identified. Intraoperative endoscopy for LRNYGBP may reduce the leak rate postoperatively and also, may minimize postoperative endoscopy and surgical intervention for gastrointestinal bleeding.

Risk factors of subsequent vertebral fracture after percutaneous kyphoplasty

Objective To evaluate the risk factors for subsequent vertebral fractures after percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compression fracture (OVCF). Methods The 95 OVCF patients who had undergone PKP from July 2005 to October 2007 were followed up to observe the incidence of subsequent vertebral fracture. Altogether 135 levels of vertebrae were involved. Statistical analyses were done to screen the risk factors associated with subsequent vertebral fractures in this group.Results The follow-ups ranged from10 to 35 months, averaging 18 months. Over the follow-up period, 19 patients (20. 0% ) sustained 25 subsequent fractures ( 18. 5% ). Twelve patients had fractures within 3 months after the operation. Secondary osteoporosis, intraoperative leakage of bone cement and fresh bone fracture were found to be correlated with subsequent vertebral fracture. Conclusions The subsequent vertebral fracture may occur in OVCF patients undergoing PKP, especially in the early postoperative months. Secondary osteoporosis, intraoperative leakage of bone cement and fresh bone fracture may be the risk factors. Key words: Vertebroplasty; Osteoporosis; Fractures, compression; Risk factor