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LEAKS IN BARIATRIC SURGERY

LEAKS IN BARIATRIC SURGERY. Paolo Gentileschi Bariatric Surgery Unit University of Rome Tor Vergata. LEAKS IN BARIATRIC SURGERY. Chirurgia gastrica in Italia. + 142%. Buchwald H, Oien DM. Obes Surg 2013;23(4):427-36 www.salute.gov.it. Chirurgia Bariatrica in Europa.

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LEAKS IN BARIATRIC SURGERY

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  1. LEAKS IN BARIATRIC SURGERY Paolo Gentileschi Bariatric Surgery Unit University of Rome Tor Vergata

  2. LEAKS IN BARIATRIC SURGERY

  3. Chirurgia gastrica in Italia + 142% Buchwald H, Oien DM. Obes Surg 2013;23(4):427-36 www.salute.gov.it

  4. Chirurgia Bariatrica in Europa Buchwald H, Oien DM. Obes Surg 2013;23(4):427-36.

  5. Chirurgia Bariatrica in Italia - 2011 Buchwald H, Oien DM. Obes Surg 2013;23(4):427-36.

  6. LEAKS

  7. Mortalità • < 30 giorni (precoce) : 0,28% • > 30 giorni (tardiva) : 0,35% Pazienti SuperObesi: • Mortalità Precoce: 1,25% • Mortalità Tardiva: 0,81% Pazienti con età> 65 anni • Mortalità Precoce: 0,34% • Mortalità Tardiva: 0,0%

  8. Postoperative Adverse Events by Bariatric Procedure in Controlled Trials. Maggard M A et al. Ann Intern Med 2005;142:547-559

  9. Obesity and Risk of Leaks Local and Systemic Factors that negatively influence suture integrity

  10. Sleeve Gastrectomy Leaks 0-6 %

  11. LEAK RATE BY PROCEDURE LAGB 0% LSG 0-7% LRYGB 0-7% LBPD 0-6%

  12. RCTs

  13. Int’l Consensus Summits on Sleeve Gastrectomy

  14. Comparative Use of Different Techniques for Leaks and Bleeding prevention during Laparoscopic Sleeve Gastrectomy M.Anselmino, N. Basso*, P. Gentileschi°, L. Angrisani§, G. Casella°, D. Benavoli°, S. D’Ugo°, P. Cutolo§, C. Moretto, R. Bellini, R.D. Berta, S. Franceschi Bariatric & Metabolic Surgery Unit, Pisa *VII Dept. of Surgery, Rome La Sapienza §Dept. Of General Surgery, S. G. Bosco Hospital, Naples °Bariatric Surgery Unit, Rome Tor Vergata

  15. Reinforced Sleeve Gastrectomy: RetrospectiveMulticenterStudy All cases of primary SG in 4 Italian Bariatric Centers

  16. Primary Sleeve Gastrectomy

  17. Competitive Landscape

  18. Reinforcement Type

  19. Results

  20. CONCLUSIONS No evidence at this time for minor incidence of leaks with either materials or oversewing Sufficient evidence of less episodes of bleeding with reinforcement with either strips

  21. LEAKS

  22. Laparoscopic Sleeve Gastrectomy

  23. Laparoscopic Sleeve Gastrectomy SERIES (Policlinico Tor Vergata Roma) March 2013 382 LSG (primary) 6 LEAKS (1.5%)

  24. Laparoscopic Sleeve Gastrectomy 5 healed with : 2 with laparoscopic drainage and TPN 3 with endoscopic clipping and stenting 1 Mortality : Pulmonary failure and sepsis

  25. IL BY-PASS GASTRICO

  26. Tardive Complicanze dopo By Pass gastrico sec. Roux Precoci (entro 30 giorni) Fistola 2-7% Embolia polmonare 0,2-1% Infezione ferita 8% Emorragia 0,8-4,4% Insufficienza respiratoria 1-4% Ernia ferita chirurgica 12-15% Occlusione intestinale 1-3% Stenosi delle anastomosi 3-7% Anemia da carenza di Ferro e/o vitamimina B12 e/o acido folico 15-33%* Osteoporosi da carenza di calcio 8-10% * Ulcera marginale 1-16%

  27. LEAKS DOPO BY-PASS GASTRICO Serie (Policlinico Tor Vergata) Marzo 2013 464 pz 1 leak anastomosi gastro-digiunale (0.2%) Re-intervento, drenaggio, NPT 1 leak anastomosi entero-entero (0.2%) Re-intervento, riconfezionamento

  28. STENTING

  29. STENTING

  30. Complicanze Precoci: LeakAnastomotici Diagnosi Leakanastomotici Segni e/o Sintomi: • Dolori addominale • Tachicardia • Iperpiressia • Aumentati segni di flogosi: VES, PCR, ProCalcitonina • Leucocitosi Neutrofila • Distress respiratorio Studio Radiologico: • Rx digerente con Gastrografin • Tc con mdc per os La II causa più comune di morte dopo RYGB • Leak Anastomosi G-J : Incidenza 2-5% - LRYGB: 5,2% - ORYGB:2,6% Mortalità 1,5% Tempo medio per la diagnosi: 2 giorni • Leak anastomosi J-J Mortalità: 40% Tempo Medio per la diagnosi: 4 giorni

  31. Leak AnastomoticiTrattamento Pz Stabile No segni di shock settico, No segni di ampio Leak Trattamento Conservativo • Digiuno • NPT • Antibtioticoterapiae.v. • SNG • STENT Presenza di Raccolta Addominale Drenaggio percutaneo TC-guidato Pz Instabile Segni shock Settico Segni radiologici di ampio Leack Reintervento Relaparoscopia Laparotomia Lavaggio raccolte intraddominali Posizionamento di Drenaggi Aspirativi Sutura diretta Leak

  32. Treated 19 patients with removable covered stents-acute leaks (n=11)-chronic fistulas (n=2) -strictures (n=6)Leaks were identified endoscopically, marked radiographically,and stents deployed under fluoroscopy. Oral feeding could be started in 79% of the patients after stenting. At a follow up of 3.6 months successful healing was achieved in : • 91% of acute leaks • 100% of gastrocutaneous fistulas • 81% of strictures Mean healing time of 30 days

  33. Treatment of Leaks and Other Bariatric Complicationswith Endoluminal Stents Treatment of acute fistola Infected fluid collection Percutaneus or laparoscopic dranaige Acute fistola Applications of stents were extended to treat esophageal and gastrointestinal leaks Healed anastomotic leak after stent removal

  34. LEAKSPREVENTIONAPPROPRIATE SURGICAL TECHNIQUESTAPLE LINE REINFORCEMENT (?)suturebuttress materialsealantsMET BLUE TESTINGNG TUBE (?)DIAGNOSISENDOSCOPY WITH FLUOROSCOPYCT SCANTREATMENTCONSERVATIVEDrainageTPNSTENTINGEndoscopic clipping or sealants (?)

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