Are routine intraoperative and postoperative leakage tests needed in bariatric surgery?

Abstract

Aim: We aimed to evaluate the efficacy of the results of intraoperative methylene blue test and postoperative upper gastrointestinal contrast graphies for detecting leakage in both primary and revisional bariatric surgery.

Methods: Two-hundred-eighty-seven patients, who underwent primary and revision bariatric surgery and routine intraoperative methylene blue test and upper gastrointestinal contrast studies postoperatively for leakage were included in the study. Patients’ demographic characteristics, comorbidities, length of hospital stay, operation time, intraoperative, and postoperative complications were analyzed retrospectively.

Results: In our study, 256 of 287 (89.1%) patients underwent primary surgery, 221 (75.7%) patients were female, the mean patient age was 38.4 ± 11.9 years, and the mean body mass index was 44.3 ± 7.6 kg/m². The number of patients who had previous abdominal surgery and comorbidity was 108 (37.6%) and 149 (51.9%), respectively. Leakage was detected by a methylene blue test in one (0.3%) patient who underwent one-anastomosis gastric bypass surgery. In one (3.2%) patient who underwent revisional surgery with negative results of methylene blue test, leakage was detected on the first postoperative day due to the clinical findings. There was no leakage detected in any patient with postoperative swallow graphies. There was no statistical difference in leakage between primary and revisional surgery groups (p = 0.23). There was no mortality.

Conclusion: It could be unnecessary to use postoperative gastrointestinal contrast studies in both primary and revisional bariatric surgery, but the routine use of the intraoperative methylene blue test could be considered useful due to its positive results for the detection of leakage.

Keywords

• Bariatric surgery,leakage,methylene blue,radio contrast imaging

Bariatrik cerrahide rutin intraoperatif ve postoperatif kaçak testlerine ihtiyaç var mı?

Öz

Amaç: Primer ve revizyonel bariatrik cerrahide kaçak tanısı için uygulanan intraoperatif metilen mavisi testi ile postoperatif üst gastrointestinal sistem kontrastlı grafilerin etkinliklerini ve sonuçlarını değerlendirmeyi amaçladık.

Yöntemler: Primer ve revizyonel cerrahi uygulanan, kaçak tespiti için rutin olarak intraoperatif metilen mavisi testi ile postoperatif üst gastrointestinal kontrastlı grafi yapılan 287 hasta çalışmaya dahil edildi. Hastaların demografik özellikleri, komorbid hastalıkları, hastanede yatış süresi, ameliyat süresi, intraoperatif ve postoperatif komplikasyonlar retrospektif olarak incelendi.

Bulgular: Çalışmamızdaki 287 hastanın 256’sına (%89,1) primer cerrahi uygulandı ve hastaların 221’i (%75,7) kadın, ortalama yaş 38.4±11.9 yıl ve ortalama beden kitle indeksi 44.3± 7.6 kg /m² idi. Daha önce abdominal cerrahi geçiren ve komorbid hastalığı olan hasta sayıları sırasıyla 108 (%37,6) ve 149 (%51,9) idi. Bir (% 0,3) tek-anastomozlu gastrik bypass olgusunda metilen mavisi testinde kaçak tespit edildi. Revizyon cerrahisi uygulanan 1 (%3,2) olguda, metilen mavisi testinde kaçak tespit edilmeyip, postoperatif 1. gün klinik bulgulara göre kaçak tespit edildi. Postoperatif kontrastlı grafi sonuçlarında hiçbir hastada kaçak tespit edilmedi. Primer ve revizyonel cerrahi uygulanan olgular arasında görülen kaçaklarda istatistiksel olarak anlamlı fark tespit edilmedi (p=0,230). Mortalite yok idi.

Sonuç: Primer ve revizyonel bariatrik cerrahide postoperatif gastrointestinal kontrast çalışmalarının kullanılmasına gerek olmayabilir, ancak kaçak tespitindeki pozitif sonuçları nedeniyle intraoperatif metilen mavisi testinin rutin olarak uygulanması düşünülebilir.

Anahtar Kelimeler

• Bariatrik cerrahi,kaçak,metilen mavisi,radyo kontrastlı görüntüleme

Kaynakça

1. 1. Nguyen NT, Varela JE. Bariatric surgery for obesity and metabolic disorders: state of the art. Nat Rev Gastroenterol Hepatol. 2017;14:160-9.
2. 2. Schulman AR, Thompson CC. Complications of Bariatric Surgery: What You Can Expect to See in Your GI Practice. Am J Gastroenterol. 2017;112:1640-55.
3. 3. Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26:1509–15.
4. 4. Arteaga-González I, Martín-Malagón A, Martín-Pérez J, Carrillo-Pallarés A. Usefulness of Clinical Signs and Diagnostic Tests for Suspected Leaks in Bariatric Surgery. Obes Surg. 2015;25:1680-4.
5. 5. Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 2013;27:240–5.
6. 6. DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass. Surg Obes Relat Dis. 2007;3:134–40.
7. 7. Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc. 2003;17:212–5.
8. 8. Oliak D, Ballantyne GH, Weber P, Wasielewski A, Davies RJ, Schmidt HJ. Laparoscopic Roux-en-Y gastric bypass: defining the learning curve. Surg Endosc. 2003;17:405–8.

9. 9. Aggarwal S, Bhattacharjee H, Chander Misra M. Practice of routine intraoperative leak test during laparoscopic sleeve gastrectomy should not be discarded. Surg Obes Relat Dis. 2011;7:e24-5.
10. 10. Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, Basso N, et al. International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8-19.
11. 11. Mbadiwe T, Prevatt E, Duerinckx A, Cornwell E 3rd, Fullum T, Davis B. Assessing the Value of Routine Upper Gastrointestinal Contrast Studies Following Bariatric Surgery: A Systematic Review and Meta-Analysis. Am J Surg. 2015;209:616-22.
12. 12. Shin RB. Intraoperative endoscopic test resulting in no postoperative leaks from the gastric pouch and gastrojejunal anastomosis in 366 laparoscopic Roux-en-Y gastric bypasses. Obes Surg. 2004;14:1067-9.
13. 13. Sethi M, Zagzag J, Patel K, Magrath M, Somoza E, Parikh MS, et al. Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy, Surg Endosc. 2016;30:883-91.
14. 14. Bingham J, Lallemand M, Barron M, Kuckelman J, Carter P, Blair K, et al. Routine intraoperative leak testing for sleeve gastrectomy: is the leak test full of hot air? Am J Surg. 2016;211:943-7.
15. 15. Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 2013;27:240–5.
16. 16. Bingham J, Kaufman J, Hata K, Dickerson J, Beekley A, Wisbach G, et al. A multicenter study of routine versus selective intraoperative leak testing for sleevegastrectomy. Surg Obes Relat Dis. 2017;13:1469-75.
17. 17. Celio AC, Kasten KR, Brinkley J, Chung AY, Burruss MB, Pories WJ, et al. Effect of surgeon volume on sleeve gastrectomy outcomes. Obes. Surg. 2016;26: 2700–4.
18. 18. Sethi M, Magrath M, Somoza E, Parikh M, Saunders J, Ude-Welcome A, et al. The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study. Surg Endosc. 2016;30:2266-75.
19. 19. Wahby M, Salama AF, Elezaby AF, Belgrami F, Abd Ellatif ME, El-Kaffas HF, et al. Is routine postoperative gastrografin study needed after laparoscopic sleeve gastrectomy? Experience of 712 cases. Obes Surg. 2013;23:1711–7.
20. 20. Mizrahi I, Tabak A, Grinbaum R, Beglaibter N, Eid A, Simanovsky N, et al. The utility of routine postoperative upper gastrointestinal swallow studies following laparoscopic sleeve gastrectomy. Obes Surg 2014;24:1415–9.