Selective nonoperative management of leaks after gastric bypass

Lessons learned from 2675 consecutive patients

Paul A. Thodiyil, Panduranga Yenumula, Tomasz Rogula, Piotr Gorecki, Bashar Fahoum, William Gourash, Ramesh Ramanathan, Samer G. Mattar, Dilip Shinde, Vincent C. Arena, Leslie Wise, Philip Schauer

Research output: Contribution to journalArticle

39 Citations (Scopus)

Abstract

Objective: To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management. Summary of Background Data: There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death. Methods: We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management. Results: Leaks occurred in 46 patients (41 women) with mean (±SD) age of 46.9 ± 8.7 years, weight and body mass index (BMI) of 307.8 ± 56.9 lb and 51.2 ± 9.5 kg/m, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P < 0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P < 0.01. There were no deaths. Conclusions: Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.

Original languageEnglish
Pages (from-to)782-792
Number of pages11
JournalAnnals of Surgery
Volume248
Issue number5
DOIs
StatePublished - Nov 2008

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Gastric Bypass
Drainage
Gastric Stump
Jejunostomy
Deglutition
Esophagus
Cause of Death
Length of Stay
Stomach
Body Mass Index
Therapeutics
Extremities
Anti-Bacterial Agents
Weights and Measures
Incidence

ASJC Scopus subject areas

  • Surgery

Cite this

Thodiyil, P. A., Yenumula, P., Rogula, T., Gorecki, P., Fahoum, B., Gourash, W., ... Schauer, P. (2008). Selective nonoperative management of leaks after gastric bypass: Lessons learned from 2675 consecutive patients. Annals of Surgery, 248(5), 782-792. https://doi.org/10.1097/SLA.0b013e31818584aa

Selective nonoperative management of leaks after gastric bypass : Lessons learned from 2675 consecutive patients. / Thodiyil, Paul A.; Yenumula, Panduranga; Rogula, Tomasz; Gorecki, Piotr; Fahoum, Bashar; Gourash, William; Ramanathan, Ramesh; Mattar, Samer G.; Shinde, Dilip; Arena, Vincent C.; Wise, Leslie; Schauer, Philip.

In: Annals of Surgery, Vol. 248, No. 5, 11.2008, p. 782-792.

Research output: Contribution to journalArticle

Thodiyil, PA, Yenumula, P, Rogula, T, Gorecki, P, Fahoum, B, Gourash, W, Ramanathan, R, Mattar, SG, Shinde, D, Arena, VC, Wise, L & Schauer, P 2008, 'Selective nonoperative management of leaks after gastric bypass: Lessons learned from 2675 consecutive patients', Annals of Surgery, vol. 248, no. 5, pp. 782-792. https://doi.org/10.1097/SLA.0b013e31818584aa
Thodiyil, Paul A. ; Yenumula, Panduranga ; Rogula, Tomasz ; Gorecki, Piotr ; Fahoum, Bashar ; Gourash, William ; Ramanathan, Ramesh ; Mattar, Samer G. ; Shinde, Dilip ; Arena, Vincent C. ; Wise, Leslie ; Schauer, Philip. / Selective nonoperative management of leaks after gastric bypass : Lessons learned from 2675 consecutive patients. In: Annals of Surgery. 2008 ; Vol. 248, No. 5. pp. 782-792.
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abstract = "Objective: To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management. Summary of Background Data: There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death. Methods: We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management. Results: Leaks occurred in 46 patients (41 women) with mean (±SD) age of 46.9 ± 8.7 years, weight and body mass index (BMI) of 307.8 ± 56.9 lb and 51.2 ± 9.5 kg/m, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P < 0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P < 0.01. There were no deaths. Conclusions: Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.",
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AU - Rogula, Tomasz

AU - Gorecki, Piotr

AU - Fahoum, Bashar

AU - Gourash, William

AU - Ramanathan, Ramesh

AU - Mattar, Samer G.

AU - Shinde, Dilip

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AU - Wise, Leslie

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N2 - Objective: To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management. Summary of Background Data: There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death. Methods: We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management. Results: Leaks occurred in 46 patients (41 women) with mean (±SD) age of 46.9 ± 8.7 years, weight and body mass index (BMI) of 307.8 ± 56.9 lb and 51.2 ± 9.5 kg/m, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P < 0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P < 0.01. There were no deaths. Conclusions: Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.

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