OBES SURG (2013) 23:1341–1343 DOI 10.1007/s11695-013-1002-3

NEW CONCEPT

New CT Scan Classification of Leak After Sleeve Gastrectomy M. Nedelcu & M. Skalli & E. Delhom & J. M. Fabre & D. Nocca

Published online: 31 May 2013 # Springer Science+Business Media New York 2013

Abstract Laparoscopic sleeve gastrectomy (LSG) has become one of the most common bariatric procedures. Even so, the gastric leak remains the most feared complication with a difficult, non-standardized treatment. The purpose of this study was to assess the feasibility of a new classification of leakage after LSG used in Montpellier University Hospital. We have studied the correlations between radiological findings and therapeutic outcome for the 20 gastric leaks. The presence of a leak was evaluated according to the day of appearance, the symptomatology, the location, severity on the CT scan, and the management. From May 2010 to September 2012, we prospectively collected data from 20 patients diagnosed with gastric leak after LSG. There were 16 women and 4 men with a mean age of 34 years old (range 21–52 years old). The fistula was diagnosed at postoperative day 28.1 days (range 3–77 days). Patients were grouped by the new classification in: 11—type I, 6—type II, 3—type III fistula, and 0—type IV. The visualization of leakage was observed for five cases (25 %). The initial surgical drainage was performed for 11 cases and the conservative treatment was preferred in 9 cases. Three cases necessitated a delayed surgical drainage after 1 week of conservative treatment. The surgical drainage was performed by laparoscopy in 12 cases and by laparotomy in 2 cases. The new CT scan classification of gastric leak could serve as a working basis for a consensus on the therapeutic management of this dreaded complication. M. Nedelcu (*) : M. Skalli : J. Fabre : D. Nocca Department of Surgery, Saint Eloi Hospital-CHRU Montpellier, 80 Av. Augustin Fliche, 34295 Cedex 5 Montpellier, France e-mail: [email protected] E. Delhom Department of Radiology, Saint Eloi Hospital-CHRU Montpellier, 80 Av. Augustin Fliche, 34295 Cedex 5 Montpellier, France

Keywords CT Scan Classification . Leak . Sleeve Gastrectomy

Introduction In 2011, laparoscopic sleeve gastrectomy (LSG) has become the most frequent bariatric procedure performed in France and is constantly increasing worldwide. Even if some of the advantages of this procedure are undisputable (lower longterm complication rate, the simplicity of the technique), still, the most feared complication remains the gastric fistula. The reported rate for the gastric leak after LSG is highly variable between 0–2.5 % for primary sleeve gastrectomies and increasing to 10 % for re-operative surgery where a previous gastric operation has been performed [1–4]. The CT scan is the most sensitive test used for leak diagnosis [5].

Methods The clinical presentation of the leak after LSG is variable, ranging from low-symptomatic patients with minimal left shoulder pain to patients presenting symptoms of sepsis with generalized abdominal tenderness and high fever, or multiple organ failure. If, for the high symptomatic patient, the surgical reintervention is mandatory, for the poor symptomatic patients, the therapeutic decision may be difficult. We propose a new classification according to the CT findings (Table. 1) with the aim to improve the management of gastric leak after LSG. The results of CT and the therapeutic decisions for the selected population with leak after LSG were prospectively collected and analyzed in order to have a management algorithm for sleeve gastrectomy leaks. For all patients, an upper endoscopy was performed to evaluate the fistulous site and the lack of stenosis.

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Table 1 New CT scan classification of leakage after LSG

Table 2 Clinical presentation— by each type of CT scan classification

Type I

Collection on CT <5 cm in LUQ

Leak

II

>5 cm in LUQ

III

Diffuse abdominal collections

IV Type S M I

Pleural (thoracic) collections Staple line localization Superior part of sleeve Middle Inferior

a b a b

Leak visualization No leak Positive leak No leak Positive leak

LSG was performed for the first time in Montpellier University Hospital in 2005 and by the end of 2012, our experience increased to 1,200 LSG. The current guidelines are according to the 1991 National Institutes of Health Consensus Conference Statement, which indicates surgery for patients whose body mass index (BMI) exceeds 40 kg/m2 or those who have a BMI of 35 to 40 kg/m2 with associated comorbid conditions [6]. A multidisciplinary team assesses every patient before confirming the indication for bariatric surgery. Operative technique: the patient is placed in a supine position; five trocars were introduced. The LSG is performed by dissecting the gastrocolic ligament, then cutting the short vessels of large curvature, beginning 6 cm proximal to the pylorus to the angle of His, without forgetting to section the posterior gastric adherences. Once the complete mobilization of the stomach is done, a special designed tube was introduced to calibrate the vertical gastrectomy. This tube was conceived with the purpose to offer a higher reproducibility of the antrum preservation technique. We are starting the stapling-section of the antrum to 6 cm from the pylorus with gold cartridges. The reinforcing of the staple line was not systematically done in our experience. The methylene blue test and the drainage were always performed. Patients are started on an oral fluid diet on postoperative day 1 in the absence of any suspicious clinical sign for leakage. The patients are discharged home uneventfully on the third postoperative day.

Results The demographic data of the patients include 16 women and 4 men with a mean age of 34 years old (range 21–52 years old). The mean time to diagnosis of the gastric leak was 28.125 days (range 3–77 days). Patients with a leak after LSG showed different degrees of symptomatology. The triad formed by abdominal pain, fever, and tachycardia is presented in Table 2.

Number

Tachycardia Fever

Type I 11 cases (55 %) 8 (72.7 %) Type II 6 cases (30 %) 5 (83.3 %) Type III 3 cases (15 %) 3 (100 %)

Abdominal pain

6 (54.5 %) 4 (45.4 %) 3 (50 %) 5 (83.3 %) 3 (100 %) 3 (100 %)

The CT scan results classified the patients as follows: & & & &

Type Type Type Type

I—11 cases; II—6 cases; III—3 cases; IV—0 cases;

The visualization of leakage was observed for five cases (25 %). According to the clinical presentation and to the CT scan results, the initial surgical drainage was done for 11 cases and no radiological drainage was attempted. The surgical drainage was performed by laparoscopy in nine cases and by laparotomy in two cases; both of them type III on the CT scan. The conservative treatment was preferred in nine cases. After 1 week of nothing by mouth, antibiotherapy, and nutritional support, three patients out of nine showed an increase of the collection on CT scan, which necessitated a delayed surgical drainage by laparoscopy. This was the first drainage 1 week after the attempt of a conservative treatment. The outcome of the rest of the six patients with type I was favorable with no need of surgical drainage.

Discussions At the beginning of the experience, the intra-abdominal abscess close to the staple line was not considered as a leak after sleeve gastrectomy. Further experience showed us that even if there is no visualization of the leakage on the CT scan, an intra-abdominal collection close to staple line must be treated as a leak. Antibiotherapy and nutritional support is the cornerstones of this treatment. Evolution is characterized by long periods of time necessary for the leak to heal. The management of the gastric leak must be tailored to each patient, but the existence of a new CT scan classification can improve it. In our initial experience, the systematic radiological control study at postoperative day (POD) 2 showed leakage in only 2 patients out of 32 (6.25 %). The systematic radiological control at POD 1 or 2 includes many false negatives results and could give a false impression of security. The majority of gastric fistulas after LSG occur after the discharge of the patient. Therefore, by the end of 2011, our team has decided to stop the systematic radiological control

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Fig. 1 Algorithm management depending on CT scan findings

and we prefer to do a thoraco-abdominal CT scan with oral opacification if clinical or laboratory findings are suggestive for fistula, or if the patient had history of vertical banded gastroplasty or gastric banding. During the follow-up of LSG, the criteria to perform a CT scan for suspicion of gastric leak are clinical signs (abdominal pain, fever or tachycardia) associated with an increased C-reactive protein >100. This new CT scan classification allows us to elaborate an algorithm management of the gastric fistula after sleeve gastrectomy, which remains to be validated by further experiences (Fig. 1). If for the types II, III, and IV the surgical drainage is mandatory, for type I, we had six patients for which the surgical intervention was avoided. For type IV fistulas, after the pleural drainage is performed in the acute setting, a multidisciplinary approach with the thoracic surgeon and the pneumologist must be considered in order to diagnose and treat a gastrobronchial fistula. We had four cases of gastro bronchial fistulas, every one necessating a pulmonary resection. These four cases of gastro bronchial fistula occurred after LSG, but at the beginning of our experience. This classification was used for the last 20 cases of gastric leak after LSG treated in our center. In our bariatric team, all the endoscopic approaches including endoprothese, endoscopic clips, endoscopic sealing glue, or balloon dilatation has been used. After 6 months of the diagnosis of gastric fistula after LSG in the case of failure of different endoscopic treatments, a definitive surgical approach is proposed to the patient. Gastric fistula remains the most feared complication after LSG mainly for two reasons. First, the clinical evolution showed us that this fistula is more difficult to close comparing to other fistulas in bariatric surgery. This is probably explained by the mechanism itself of the sleeve gastrectomy, which means the creation of a high-pressure gastric tube. The second reason is represented by the lack of standardization in the management of the fistula, especially when this one becomes a chronic fistula.

Conclusions The knowledge of the diverse radiologic appearances of these complications, as well as the familiarity with its clinical settings is vital for prompt and effective treatment. CT scan with oral contrast should be performed in all patients with clinical suspicion of gastric leak after LSG. The use of the new CT classification could ameliorate the management of gastric fistula and improve the standardization of the results reported in different future studies. Diagnosis of a leak after a LSG requires a greater index of suspicion in order to perform an early diagnosis. Sepsis control and nutritional support are the cornerstones of this treatment. Management must be tailored to each patient. Conflict of Interest The authors M. Nedelcu, M. Skalli, E. Delhom, J.M. Fabre, and D. Nocca have no conflicts of interest or financial ties to disclose.

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