Probably the Mycobacterium avium Complex around the Staple Line Exacerbated after Radiation Therapy

The space around the staple line after lung surgery is at high risk of nontuberculosis Mycobacterium pulmonary disease (NTM-PD). Solitary nodules of NTM-PD around the staple line are difficult to distinguish from lung cancer. There is no clear identification from laboratory data and radiologic findings without histological examination. In the present case, we misdiagnosed the pulmonary granulomas with Mycobacterium avium complex pulmonary disease (MAC-PD) as a recurrence of lung cancer. We conducted radiation therapy. The pulmonary granulomas with MAC-PD were exacerbated by irradiation. The effects of radiation therapy for MAC-PD are unknown. When radiation therapy is performed for the patient coexistence with MAC-PD, we should pay attention to exacerbation of MAC-PD.

Is Staple LRE to Prevent Post-Operative Staple Line Leak and Haemorrhage after Laparoscopic Sleeve Gastrectomy

Background: Staple line haemorrhage and leak are considered to be common complications of laparoscopic sleeve gastrectomy. Some strongly recommend staple line reinforcement to deal with these complications while some consider it non beneficial. Aim: To analyze if staple line reinforcement is essential to prevent staple line haemorrhage and leaks. Methods: This retrospective study was conducted in Surgical unit 1 Fatima Memorial Hospital. A total of 100 patients were selected and divided into two groups of 50 each. Group 1 had staple line reinforced while group 2 had no reinforcement at all. All patients were observed for 24-48 hours for post-operative bleeding and leak. Results: Staple line leakage was found to be 4% in patients with staple line reinforcement whereas it was 6% in patients without staple line reinforcement with a p value of 0.284 which was not significant. Likewise, staple line bleeding in both groups were 2% and 6% with p value of 0.129 which was also insignificant. Conclusion: There is no added benefit to reinforce the staple line to prevent postoperative leak or bleeding but reinforcement only prolongs the operation time. Keywords: Laparoscopic sleeve gastrectomy, leak, post-operative bleeding, staple line reinforcement

Role of Rendezvous-Procedure in the Treatment of Complications after Laparoscopic Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric procedures worldwide with good results, high patient acceptance, and low complication rates. The most relevant perioperative complication is the staple line leak. For the treatment of this complication, endoscopic negative pressure therapy has proven particularly effective. The correct time to start endoscopic negative pressure therapy has not been the subject of studies to date. Methods: Twelve patients were included in this retrospective data analysis over three years. Endoscopic negative pressure therapy was carried out using innovative open pore suction devices. Patients were treated with simultaneous surgery and endoscopy, so called rendezvous-procedure (Group A) or solely endoscopically, or in sequence surgically and endoscopically (Group B). Therapy data of the procedures and outcome measures, including duration of therapy, therapy success, and change of treatment strategy, were collected and analysed. Results: In each group, six patients were treated (mean age 52.96 years, 4 males, 8 females). Poor initial clinical situation, time span of endoscopic negative pressure therapy (Group A 31 days vs. Group B 18 days), and mean length of hospital stay (Group A 39.5 days vs. Group B 20.17 days) were higher in patients with rendezvous procedures. One patient in Group B died during the observation time. Discussion: Rendezvous procedures for patients with staple line leaks after sleeve gastrectomy is indicated for serious ill patients with perigastric abscesses and in need of laparoscopic lavage. The one-stage complication management with the rendezvous procedure seems not to result in an obvious advantage in the further outcome in patients with staple line leaks after laparoscopic sleeve gastrectomy.

Impact of the calibration bougie diametre during laparoscopic sleeve gastrectomy on the rate of postoperative staple-line leak (BOUST): study protocol for a multicentre randomized prospective trial

Background Laparoscopic sleeve gastrectomy (LSG) has become an increasing bariatric procedure. The basic principle is to create a narrow stomach along the lesser curvature, using a calibration bougie as a template to perform a vertical partial gastrectomy, resecting the greater curvature and fundus of the stomach. The most common postoperative complication is gastric leak from the staple line, observed in approximately 3% of cases, which can result in long and incapacitating treatment. The diametre of the bougie used to calibrate the remnant stomach could impact the rate of postoperative gastric leak, a higher diametre being correlated with a lower risk of leak, without lowering long-term weight loss. This is the first randomized trial to compare the outcomes of LSG regarding the use of two different bougie diametres on postoperative gastric leak and mid-term weight loss. Methods Bougie Sleeve Trial (BOUST) is a superiority single-blinded randomized national trial, involving 17 centres. Participants will be randomized into two groups. LSG will be performed using a 48-Fr diametre calibration bougie in the experimental group and a standard care (34 to 38-Fr diametre) calibration bougie in the control group. Both groups will take part in a 2-year postoperative follow-up to assess postoperative gastric leak rate and weight loss and quality of life evolution. Discussion This study protocol will allow the investigators to determine if the use of a larger calibration bougie during LSG is associated with lower postoperative gastric leak occurrence without impairing mid-term weight loss and quality of life. The results of this trial will provide important data on patient safety and promote best practice for LSG procedures. Trial registration ClinicalTrials.govNCT02937649. Registered on 18 October 2016

Esophageal Stent in Sleeve Gastrectomy Leak Treatment: Observations Based on a Challenging Surgical Case and Literature

Gastric leak is a serious complication of sleeve gastrectomy with a well-documented morbidity and mortality. Depending on the series the leak rate ranges between 1 and 5%. The treatment of sleeve gastrectomy leak is still challenging. Different procedures have been described in management of gastric leak, both surgical and endoscopic. The treatment of gastric leaks depends on the extent of the staple-line leak, the site of the leak and its association with stenosis. As published data are limited, there are no still standardized guidelines on best treatment. One of the most commonly used option in the treatment of gastric leak is esophageal stent. Its success rate reaches 70–80% but it is burdened by some complications. Stent migration is the most common complication in the placement of esophageal stent.We present a challenging surgical in which case the use of an esophageal stent for the treatment of a sleeve gastrectomy leak gained the resolution of the leak but was complicated by bowel obstruction due to migration of the stent.

Successful revision surgery for very late-onset stomal obstruction following Gomez gastroplasty: a case report

Background Gomez gastroplasty, which was developed in the 1970s as one of the gastric restrictive surgeries for severe obesity, partitions the stomach using a stapler from the lesser towards the greater curvature at the upper gastric body, leaving a small channel. This procedure is no longer performed due to poor outcomes, but surgeons can encounter late-onset complications even decades after the surgery. Here, we report a case of very late-onset stomal obstruction following Gomez gastroplasty which was successfully treated by revision surgery. Case presentation A 58-year-old man was referred to our institution with sudden-onset nausea and vomiting. He underwent weight loss surgery in the USA in 1979, but the details of the surgery were unclear. Esophagogastroduodenoscopy demonstrated a stoma at the greater curvature of the upper gastric body, and fluoroscopy showed retention of contrast medium in the fundus and poor outflow through the stoma. Abdominal computed tomography revealed a staple line partitioning the stomach. Considering these preoperative investigation findings and the period during which the surgery was performed, the patient was diagnosed with very late-onset stomal obstruction following Gomez gastroplasty. Supporting the preoperative diagnosis, the surgical findings revealed a staple line extending from the lesser towards the greater curvature of the upper gastric body and a channel reinforced by a running seromuscular suture on the greater curvature. Moreover, gastric torsion caused by the enlarged proximal gastric pouch was found. Re-gastroplasty involving wedge resection of the original channel was performed followed by construction of a new channel. Postoperative course was uneventful, and the patient no longer had symptoms of stomal obstruction after revision surgery. Conclusions Re-gastroplasty was safe and feasible for very late-onset stomal obstruction following Gomez gastroplasty. Accurate preoperative diagnosis based on the patient’s interview and the investigation findings was important for surgical planning. A careful follow-up is required to prevent excessive weight regain after revision surgery.

A Practical Strategy of Controlled Monopolar Cautery With/Without Oversewing for Staple Line Bleeding in Bariatric Surgery: A Single Center Experience

Introduction In laparoscopic bariatric surgery, stapling devices are essential for creating a gastric tube or gastric pouch. Staple line bleeding (SLB) is an important issue, but the effect of monopolar cautery for SLB control is unclear. This study aimed to evaluate the outcomes of controlled monopolar cautery with/without oversewing for SLB control during bariatric surgery. Materials and Methods From January 2019 to May 2021, 66 patients underwent bariatric surgery with controlled monopolar cautery with/without oversewing for SLB control. Patient demographics and intraoperative and postoperative outcomes were analyzed. Results This study enrolled 35 women and 31 men (mean age: 38.1 years; mean body mass index: 39.8 kg/m2). All patients had varying degrees of SLB. Controlled monopolar cautery was applied to 63 patients with ≤6 bleeding sites. Only two patients needed further partial oversewing of the bleeding sites after controlled monopolar cautery failed to achieve hemostasis. Initially, three patients had more than six bleeding sites, and thus complete oversewing was performed to achieve successful hemostasis. There was no intraabdominal or gastrointestinal bleeding. There were one gastric stricture, one anastomotic leakage, and one staple line leakage. Conclusions The strategy of controlled monopolar cautery with/without oversewing is a simple, practical, inexpensive, and safe method for SLB control during bariatric surgery.