Suture Line Leak Research Articles

Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience

Esophageal epiphrenic diverticula are uncommon. Traditionally, thoracotomy has been the preferred surgical approach. Recently, minimally invasive approaches have been reported in a few series. However, the best surgical approach remains uncertain. In this study, we review the results of 25 articles discussing laparoscopic or thoracoscopic surgery. From January 1995 to December 2008, there were a total of 133 patients reported in English-language journals in PubMed. Nineteen patients (14 %) underwent thoracoscopic surgery, 112 (84 %) laparoscopic surgery and two patients (2 %) were treated using a combination approach. The diverticulectomy was performed using an endostapler device in all patients. A myotomy was added in 103 patients (83 %). A fundoplication was added in 106 patients (85 %). There were two deaths during surgery (2 %). The post-operative morbidity rate was 21 %. The most severe complication was suture-line leakage, which occurred in 20 patients (15 %). Recently, we successfully treated a patient with an epiphrenic esophageal diverticulum by performing a minimally invasive laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication after observing its enlargement on radiological and endoscopic examinations over 2 years. We believe laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication may therefore become the standard treatment modality for minimally invasive surgery for esophageal epiphrenic diverticulum.

Use of a specially designed partially covered self-expandable metal stent (PSEMS) with a 40-mm diameter for the treatment of upper gastrointestinal suture or staple line leaks in 11 cases

The use of self-expandable stents to treat postoperative leaks and fistula in the upper gastrointestinal (GI) tract is an established treatment for leaks of the upper GI tract. However, lumen-to-stent size discrepancies (i.e., after sleeve gastrectomy or esophageal resection) may lead to insufficient sealing of the leaks requiring further surgical intervention. This is mainly due to the relatively small diameter (≤30 mm) of commonly used commercial stents. To overcome this problem, we developed a novel partially covered stent with a shaft diameter of 36 mm and a flare diameter of 40 mm. From September 2008 to September 2010, 11 consecutive patients with postoperative leaks were treated with the novel large diameter stent (gastrectomy, n = 5; sleeve gastrectomy, n = 2; fundoplication after esophageal perforation, n = 2; Roux-en-Y gastric bypass, n = 1; esophageal resection, n = 1). Treatment with commercially available stents (shaft/flare: 23/28 mm and 24/30 mm) had been unsuccessful in three patients before treatment with the large diameter stent. Due to dislocation, the large diameter stent was anchored in four patients (2× intraoperatively with transmural sutures, 2× endoscopically with transnasally externalized threads). Treatment was successful in 11 of 11 patients. Stent placement and removal was easy and safe. The median residence time of the stent was 24 (range, 18-41) days. Stent dislocation occurred in four cases (36 %). It was treated by anchoring the stent. Mean follow-up was 25 (range, 14-40) months. No severe complication occurred during or after intervention and no patient was dysphagic. Using the novel large diameter, partially covered stent to seal leaks in the upper GI tract is safe and effective. The large diameter of the stent does not seem to injure the wall of the upper GI tract. However, stent dislocation sometimes requires anchoring of the stent with sutures or transnasally externalized threads.

Laparoscopic sleeve gastrectomy in obese adolescents: results in 51 patients

BackgroundAdolescent obesity has become an important health problem. Bariatric surgery in this population continues to be a matter of debate. The aim of our study was to present our experience and results with laparoscopic sleeve gastrectomy (LSG) in obese adolescents at the digestive surgery department of the Hospital Clínico Pontificia Universidad Católica de Chile. MethodsObese adolescent patients <19 years old underwent LSG from January 2006 to October 2009. The percentage of excess weight loss and quality of life were analyzed. ResultsA total of 51 patients aged <19 years underwent LSG. Of these, 80.4% were girls and aged 15–19 years (mean age 18 ± 1.45). The mean preoperative weight and body mass index was 98 ± 13.3 kg and 38.5 ± 3.7 kg/m2, respectively. Of these patients, 76% had preoperative co-morbidities, including insulin resistance in 59.2%, dyslipidemia in 23.5%, hepatic steatosis in 16%, and type 2 diabetes mellitus in 3.9%. The operative time was 69 ± 24 minutes, with a 2.8 ± 20.6-day postoperative hospital stay. No conversion to open surgery was necessary. One patient had a suture line leak that required both endoscopic and laparoscopic treatment. The percentage of excess weight loss at 6 months and 1 and 2 years was 94.6%, 96.2%, and 92.9%, respectively. Of the 76% of patients with preoperative co-morbidities, all resolved or improved their condition. In the quality of life survey (Moorehead-Ardelt Quality of Life Questionnaire) conducted, all reported very good or good quality of life after surgery (40% and 60%, respectively). ConclusionIn our experience, LSG as a treatment of obese adolescent patients is safe, with good short-term weight loss and resolution of co-morbidities.

Laparoscopic Repair of Epiphrenic Diverticulum

Epiphrenic diverticulum of the esophagus is an uncommon disease, and its pathogenesis remains unclear. Surgical repair of this disease is warranted only for symptomatic patients because treatment carries high risk of morbidity. Over the past decade, the laparoscopic approach to epiphrenic diverticulectomy has been shown to be safe and effective. The aim of the study was to describe our specific approach to the procedure and results. From 1994 to 2012, 30 patients with symptomatic epiphrenic diverticulum underwent laparoscopic surgery. There were no conversions to open surgery. The postoperative course was uneventful in 28 patients (93.3%). One patient had a suture line leak, which required repair through right thoracotomy, and 1 patient had a hemoperitoneum, which needed an open splenectomy. The median follow-up was 52 months (2-144). To date, no patient has presented with a recurrence. Laparoscopic transhiatal surgery is in our opinion the preferred approach to treatment of epiphrenic diverticulum of the esophagus. The procedure has proven to be feasible and safe in experienced hands. Long-term results, both clinical and with an objective evaluation, are satisfactory.

Laparoscopic Repair of Epiphrenic Diverticulum

Epiphrenic diverticula (ED) are a rare clinical entity characterized by out-pouchings of the esophageal mucosa originating in the distal third of the esophagus, close to the diaphragm. The proportion of diverticula reported symptomatic enough to warrant surgery is extremely variable, ranging from 0% to 40%. The natural history of ED is still almost unknown and the most intriguing question concerns whether or not they all need surgical treatment. From 1993 to 2010 35 patients underwent surgery at our institution. Eleven patients were treated via a thoracotomic approach alone and were excluded from present study. The remaining 24 patients formed our study population. Seventeen patients (48.6%) underwent surgery via a purely laparoscopic approach, and received a diverticulectomy + myotomy + antireflux procedure. Seven patients (23%), with ED positioned well above inferior pulmonary vein, were treated via a combined laparoscopic-thoracotomic approach: they all underwent diverticulectomy + myotomy + an antireflux procedure. Mortality was nil. The overall morbidity rate was 25%. A suture leakage occurred in 4 patients (16.6%) and they were all conservatively treated. Patients' symptom scores decreased from a median of 15 to 0 (P = 0.0005). Laparoscopic surgery for ED is effective, but given the not negligible incidence of complications such suture-line leakage, should be considered only in symptomatic patients or in event of huge diverticula. A tailored combined laparoscopic-thoracotomic approach may be useful in case of ED located high in mediastinum or with large neck.

P-28 Sleeve gastrectomy before laparoscopic ROUX-en-Y gastric bypass (LRYGB) as a staged procedure for super super obese patients-safety and outcomes

scopic Gastric Bypass (LGB) in general and in subgroups of patients with pre-operative BMI less and more than 50 kg/m. Methods: Retrospective study of patients undergoing VSG and LGB for a period of 3 years. Results: In 2007-2010 VSG was performed in 93 and LGB in 860 patients. Mortality was 0% and 0.11%, respectively. Major morbidity was 6.3% and 4.5%. Baseline BMI was 47.5 kg/m and 49.8 kg/m, excess body weight 143.9 lbs and 155.5 lbs. Average length of stay 2 days. There were 3 proximal suture line leaks and one intractable stricture requiring revision to LGB in VSG group. One delayed leak over suture line presenting 6 months post-operatively with abdominal wall abscess. At 1, 2 and 3 year of follow-up %EBWL were 66%, 67% and 65% in VSG group compared to 67%, 69% and 65% in LGB group. Both groups of patients had decreased their BMI by 15-16 kg/m. When stratified by preoperative BMI 50 kg/m and 50 kg/m both VSG and LGB patients continued to demonstrate similar patterns of %EBWL. There is obvious higher percentage %EBWL with both VSG and LGB in patients with BMI 50 kg/m. Conclusion: Preliminary results indicate that VSG is capable of producing weight loss results comparable to gastric bypass with medium length follow-up. While seemingly a technically simple procedure VSG is prone to higher morbidity and requires meticulous execution. Effectiveness of vertical sleeve gastrectomy as a primary procedure in patients with BMI 50 kg/m is actually higher than in insurance mandated coverage group of mega-obese patients.

La gastrectomie longitudinale ( sleeve gastrectomy) comme unique chirurgie bariatrique : résultats d’une étude rétrospective multicentrique de 446 patients

Sleeve gastrectomy as an isolated procedure is a new option in bariatric surgery. The aim of this study was to evaluate its short and medium term (2 years) results in a multicenter setting. This is a retrospective study including 446 patients undergoing surgery in 14 teaching, private, and public hospitals. The immediate post-operative course were uneventful in 83.3% of patients. Minor complications occurred in 10.9% of patients and major complications in 5.3%. Suture line leaks occurred in 4.3% of the whole series. There was no mortality and the rate of reoperation was 2%. Overall mean weight loss after two years was 32 kg and the mean excess weight loss was 62%. Weight loss was significantly greater in non super-obese patients (p=0.0003). This study confirms the feasibility of sleeve gastrectomy in a multicenter setting; it is efficacious at two years as an isolated bariatric procedure for non super-obese patients. It is possible that an additional second-stage procedure may be necessary for super-obese patients.

Pancreas sparing duodenectomy as an emergency procedure

BackgroundThe operative techniques to close extensive wounds to the duodenum are well described. However, postoperative morbidity is common and includes suture line leak and the formation of fistulae. The aim of this case series is to present pancreas sparing duodenectomy as a safe and viable alternative procedure in the emergency milieu.MethodsFive patients underwent emergency pancreas sparing duodenal excisions. Re-implantation of the papilla of Vater or the papilla with a surrounding mucosal patch was performed in two patients. In one, the procedure was further supplemented with a duodenocholangiostomy, stapled pyloric exclusion and enterogastrostomy to defunction the pylorus. In another three patients, distal duodenal excisions were done.ResultsIn four patients, an uneventful recovery was made. One patient died following a myocardial infarction. The surgery lasted meanly 160 minutes with average blood loss of approximately 500 milliliters. The mean hospital stay was 12 days. Enteral nutrition was introduced within the 20 hours after the surgery. Long term follow-up of all surviving patients confirmed a good outcome and normal nutritional status.ConclusionBased on the presented series of patients, we suggest that pancreas-sparing duodenectomy can be considered in selected patients with laceration of the duodenum deemed unsuitable for surgical reconstruction.

Surgical Treatment of Epiphrenic Diverticula: A 30-Year Experience

Epiphrenic diverticula are rare and associated with esophageal motility abnormalities. Their optimal surgical treatment is debated, mortality being 9% in the largest reported surgical series of 33 patients. Our experience with a traditional thoracic approach was reviewed to provide benchmark data against which newer surgical techniques can be measured. A retrospective review of 35 patients operated on for epiphrenic diverticula from 1976 to 2005 was conducted. All underwent open transthoracic operations: resection of the diverticulum, long esophagomyotomy, and antireflux operations (modified Belsey, 29 patients; Nissen, 4 patients) in 33 patients; resection and long myotomy alone in 1 patient; and plication, long myotomy, and Collis-Nissen in 1 patient. Preoperative assessment included barium esophagogram, flexible esophagoscopy, manometry, and standard acid reflux test. Operative complications and functional results were assessed. Median age was 71 years (range, 36 to 87 years). Diverticulum size averaged 6.4 cm (range, 3 to 14 cm). Sixty-eight percent presented to the right of the esophagus. The median duration of symptoms was 3 years. Presenting complaints included dysphagia (83%), regurgitation (69%), and chest pain (26%). Eighteen had a mean weight loss of 19 pounds. There was 1 perioperative death (2.8%) from a plicated diverticulum leak and one nonfatal suture line leak. Median hospital stay was 7 days. Mean follow-up was 45.3 months. Twenty-six patients (74%) had an excellent result (no residual symptoms). Seven required a periodic esophageal dilatation for intermittent mild dysphagia. Traditional transthoracic resection, long esophagomyotomy, and an antireflux procedure provide excellent long-term functional results with relatively low postoperative morbidity in patients with epiphrenic diverticula.

Modified Posterior Sagittal Transanorectal Approach in Repair of Urogenital Sinus Anomalies

To describe the operative details and results of a modified posterior sagittal transanorectal approach for the reconstruction of urogenital sinus (UGS) anomalies. Six children with UGS anomalies underwent surgery using this technique. In a prone jack-knife position, a midline incision was continued to the puborectalis muscle. A plane of dissection was created circumferentially around the rectum separating it from the underlying UGS. Circumferential transanal mucosectomy and a transanal dissection was carried proximally for 5 to 10 cm. The mucosal tube with the serosal wall was resected, exposing the proximal part of the UGS. The posterior and anterior sphincters, anus, and perineal body were then divided in the midline, completely exposing the UGS. Reconstruction of the urethra and vagina was done. At completion of UGS reconstruction, an endoanal pull through of the rectal tube and a low coloanal anastomosis were performed. The muscle complex and perineal body were closed in layers. The modified technique of posterior sagittal transanorectal approach allowed excellent exposure in all 6 patients. None developed any complications related to suture line leak. Fecal and urinary continence was preserved in patients who were continent before the operation. The modified posterior sagittal transanorectal approach is a safe and effective technique in the treatment of UGS anomalies and can be performed without the need for a protective colostomy.

Comparative Evaluation of Suture Materials and Suture Techniques for the Management of Traumatic Teat Lesions in Buffaloes

Tiwary, R., Hoque, M., Maiti, S.K., Singh, G.R. and Kumar, N. 2006. Comparative evaluation of suture materials and suture techniques for the management of traumatic teat lesions in buffaloes. J. Appl. Anim. Res., 29: 33–36. To evaluate two suture materials and techniques in teat surgery, sixteen buffaloes with teat lesions were divided into four equal groups. Internal suturing included single layer continuous lockstitch with catgut 3-0 (group A), single layer continuous lockstitch with polyglycolic acid (PGA) 3-0 (group B), double layer simple continuous with catgut 3-0 (group C) and double layer simple continuous with PGA 3-0 (group D). Double layer simple continuous suturing with PGA reported best results followed by double layer suturing with catgut. Suture line leakage and complications were more common with single layer lockstitch patterns. Double layer suturing of teat lesions with PGA and catgut provided functional recovery of the teat, however, PGA had an edge over catgut.

Relaparotomy for postoperative intra-abdominal sepsis in jaundiced patients.

During the period 1979-84, 30 abdominal re-explorations were performed for postoperative intra-abdominal sepsis and single or multiple organ failure in jaundiced patients. Postoperative sepsis was caused by intra-abdominal abscess in 16 cases (53 per cent), by suture line leakage in 9 cases (30 per cent) and by technical error in 5 cases (17 per cent). Abscesses occurred most commonly in the subphrenic space (6 cases), in the subhepatic space (6 cases) and in the lesser sac (5 cases). Sepsis was associated with single organ failure in 20 cases and with multiple organ failure in 10 cases. The overall mortality rate was 50 per cent (15/30). Factors that were statistically associated with fatal outcome were: serum bilirubin greater than 100 mumol/l (P less than 0.008), positive blood culture (P less than 0.013), malignant disease (P less than 0.02), multiple organ failure (P less than 0.02) and age greater than 60 years (P less than 0.031). Mortality rose with the number of failed organs. Autopsy revealed continuing sepsis in 12 of the 15 fatal cases. Because mortality was high in spite of adequate operative drainage at relaparotomy, it is concluded that earlier definitive diagnostics are needed to lower the mortality rate.

Single layer anastomosis after rectosigmoid resection.

Anastomosis after resection of the rectosigmoid colon is often followed by leakage at the suture line. When occult leakage discovered on routine contrast study is included incidence rates of over 50 per cent have recently been reported. A single layer interrupted seromuscular inverting technique was used for the anastomosis after elective rectosigmoid resection in 52 consecutive patients. The total incidence of suture line leakage was 6 per cent. Therefore a high incidence of anastomotic dehiscence in the rectum can be avoided and it is concluded that a single layer technique is sound.

Endoscopic Repair of a Post-Operative Gastro-Cutaneous Fistula

Post-operative gastrocutaneous or enterocutaneous fistula are frequent surgical complications. They are difficult to treat and have high morbidity and mortality. We present endoscopic repair of one such case with fibrin glue application. A 33-year-old woman with morbid obesity had undergone open Roux-en-Y gastric bypass surgery two years ago. She then underwent laproscopic re-do surgery. Her immediate post op course was complicated by suture line leakage that required repair and jejunostomy tube placement. Three months later she presented with persistent drainage (∼800 mL/ day) through two JP drains. Gastrograffin study showed a gastro-cutaneous fistula. Endoscopically both JP drains were visualized intraluminally just distal to the anastomosis site consistent with erosion through the gastric pouch wall. This was confirmed by methylene blue and contrast dye injection. Both JP drains were removed and the tract was infiltrated with 4 ml of fibrin tissue glue using a 7 french catheter. Complete occlusion was documented. Subsequent computerized tomography with oral contrast as well as gastrograffin study revealed no extravasation. [figure 1] Two repeat endoscopic application of fibrin tissue glue, at one week and four weeks interval, resulted in complete closure of the fistula. Complete closure was documented by gastrointestinal series performed with dilute barium at six weeks. Fibrin tissue glue is a tissue-compatible glue used in various surgical fields for more than a decade to prevent bleeding. It promotes wound healing by forming matrix-building strands, and promoting neovascularization and fibroblast proliferation. In our case it successfully treated the post-operative fistula and prevented the need for a complicated surgical repair. Literature review does not reveal any such case from United States. With increasing number of the bariatric surgeries in US, endoscopic repair of such complications is likely to be increasingly valuable, and fibrin tissue glue can be a very useful adjunct to that.Figure

Isolated double gastric rupture as a result of blunt abdominal trauma

Isolated double gastric rupture as a result of blunt abdominal trauma

Role of routine intraoperative endoscopy in laparoscopic bariatric surgery.

Laparoscopic bariatric surgery is a challenging procedure with a high risk of technical misadventures that may increase postoperative morbidity. Routine intraoperative endoscopy may reduce postoperative morbidity. This article reviews our 6-year experience. From April 1995 to September 2001, we performed 825 laparoscopic bariatric procedures: 743 roux gastric bypasses, 55 vertical banded gastroplasties, 18 laparoscopic adjustable gastric bands, and 9 gastric pacemakers. All the patients underwent flexible endoscopy by the primary surgeon at completion of the operation to assess for technical errors. The 34 intraoperative technical errors (4.1%) identified included 29 suture and staple line leaks, 2 bougie perforations, 2 inadvertent stoma closures secondary to the suture line, and 1 mucosal perforation in a gastric pacemaker. All the errors were successfully repaired laparoscopically at the time of the procedure. Three leaks occurred postoperative (0.36%): 1 in the 34 repaired errors (2.9%) and 2 in the remaining 791 patients (0.25%). Routine intraoperative endoscopy identified 34 correctable technical errors in a series of 825 laparoscopic bariatric procedures. Of these, 33 (97%) were repaired successfully, which reduced postoperative morbidity.

Improving Outcomes Following Penetrating Colon Wounds

During World War II, failure to treat penetrating colon injuries with diversion could result in court martial. Based on this wartime experience, colostomy for civilian colon wounds became the standard of care for the next 4 decades. Previous work from our institution demonstrated that primary repair was the optimal management for nondestructive colon wounds. Optimal management of destructive wounds requiring resection remains controversial. To address this issue, we performed a study that demonstrated risk factors (pre or intraoperative transfusion requirement of more than 6 units of packed red blood cells, significant comorbid diseases) that were associated with a suture line failure rate of 14%, and of whom 33% died. Based on these outcomes, a clinical pathway for management of destructive colon wounds was developed. The results of the implementation of this pathway are the focus of this report. Patients with penetrating colon injury were identified from the registry of a level I trauma center over a 5-year period. Records were reviewed for demographics, injury characteristics, and outcome. Patients with nondestructive injuries underwent primary repair. Patients with destructive wounds but no comorbidities or large transfusion requirement underwent resection and anastomosis, while patients with destructive wounds and significant medical illness or transfusion requirements of more than 6 units/blood received end colostomy. The current patients (CP) were compared to the previous study (PS) to determine the impact of the clinical pathway. Outcomes examined included colon related mortality and morbidity (suture line leak and abscess). Over a 5.5-year period, 231 patients had penetrating colon wounds. 209 survived more 24 hours and comprise the study population. Primary repair was performed on 153 (73%) patients, and 56 patients had destructive injuries (27%). Of these, 40 (71%) had resection and anastomosis and 16 (29%) had diversion. More destructive injuries were managed in the CP group (27% vs. 19%). Abscess rate was lower in the CP group (27% vs. 37%), as was suture line leak rate (7% vs. 14%). Colon related mortality in the CP group was 5% as compared with 12% in the PS group. The clinical pathway for destructive colon wound management has improved outcomes as measured by anastomotic leak rates and colon related mortality. The data demonstrated the need for colostomy in the face of shock and comorbidities. Institution of this pathway results in colostomy for only 7% of all colon wounds.

Influence of two-dimensional and three-dimensional imaging on endoscopic bowel suturing.

Several three-dimensional (3-D) video-endoscopic systems have been introduced in surgical practice to enhance depth perception during minimal access surgery (MAS), but the facilitation of endoscopic manipulations by the current 3-D systems remains unproved. The aim of the study was to investigate the influence of 2-D and 3-D imaging modalities on intracorporeal suturing. The standard task consisted of suture closure of 60 mm enterotomies made in porcine small bowel with continuous seromuscular 3/0 Polysorb. Ten experienced surgeons participated in the study. The imaging systems were Storz (2-D), Welch Allyn (3-D), and Zeiss (as both 2-D and 3-D). Each surgeon performed two tasks with each modality in a random sequence. The outcome measures were execution time, suture line leakage pressure, and suture placement score. In addition, the participating surgeons assigned subjective scores on the image quality and the adverse effects of the imaging systems. There was no significant difference in the execution time, leakage pressure, and suture placement score among the various imaging modalities. Depth perception was rated as similar with 2-D and 3-D imaging. Surgeons experienced visual strain with the three systems, but it was rated higher with 3-D imaging. With the current technology, we have not documented any significant difference in task efficiency and quality of endoscopic bowel suturing by trained surgeons between 2-D and 3-D imaging systems.

Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses

Background: The mortality of thoracic anastomotic leakage following esophageal reconstruction has been reported to be as high as 60%. Early septic fulminant suture line leaks require rethoracotomy. In addition, however, clinically symptomatic leaks may also occur 2 to 7 days after resection of the esophagus. Methods: Among 80 esophageal reconstructions performed between January 1994 and July 1998, a total of 7 (8.75%) clinically apparent leaks of thoracic anastomoses were observed. The standard treatment consisted of endoscopic lavage, drainage and subsequent closure of the defect by repeated intraluminal and submucosal applications of fibrin glue. In 2 patients a novel approach permitting rapid closure by plugging the fistula with a Vicryl-cylinder was tried. In 4 patients the effect of endoscopic treatment on the HLA-DR expression on monocytes was investigated and compared to 6 patients with intact anastomoses. Results: All 7 patients were successfully treated via endoscopy. The cylinder plug achieved immediate closure of the leak. The measured change in HLA-DR expression reflected the improvement in the inflammatory response and thus documented the success of endoscopic treatment. Conclusions: Endoscopic management of thoracic leakages represents a safe and relatively noninvasive therapeutic option.

Mustard Operation

Mustard Operation