Intraoperative endoscopy may decrease post operative leak & stenosis in gastric bypass and sleeve gastrectomy

Mohamed B Al Hadad, MD, Nidal Dehni, MD, Abdelrahman A Nimeri, MD. Division of general, thoracic and vascular surgery Sheikh Khalifa Medical City managed by Cleveland clinic.

Introduction: Morbid obesity is a global epidemic and bariatric surgery in the only available long term solution. Laparoscopic Roux en Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are among the possible solutions for this problem. Anastomotic or staple line leaks as well as stenosis after RYGB and LSG are causes of major morbidity and mortality. Many ways has been used to reduce these risks. The aim of the study is to evaluate the role of intraoperative endoscopy in reducing these risks.

Methods: We retrospectively reviewed our entire consecutive primary and revisional RYGB and LSG cases done between June 2009 – Sep 2013. Our technique for RYGB is hand sewn gastrojejunostomy and for LSG is to oversew and invert the entire staple line. We perform intraoperative endoscopy to check for leak, bleeding or stenosis at the end of all cases with an adult 32 Fr endoscope. No drains are placed and we do not perform UGI study after surgery. Whenever an intraoperative leak test under water is positive, we reinforce with sutures, omental patch and fibrin sealant agent. In addition, a drain or Gastrostomy tubes are placed and an UGI study is done on postoperative day number 1.

Results:We performed 444 cases (299 RYGB and 145 LSG) during the study period. Intraoperative endoscopy was performed in 100% of our cases. An intraoperative leak test was positive in 6/299 (2%) RYGB and 0/145 LSG cases. We had 3/299 (1%) clinical leaks after RYGB, and 0/145 clinical leaks after LSG. one of the 3 RYGB leaks had a positive intraoperative leak and that patient had a drain and a gastrostomy tube placed and did not need reoperation. In addition, the intraoperative endoscopy detected 3 cases where we detected a LSG that was too tight. and sutures were removed to correct the size or the configuraton of the LSG. We had no clinical stenosis or twist in our LSG.

Conclusion:We believe performing intraoperative endoscopy has allowed us to change our intraoperative management strategy in RYGB and LSG cases. This changes has led to a low leak and stenosis rate in our series.

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