Management of leakage and fistulas after bariatric surgery

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“Leaks and fistulas are among the most feared complications of bariatric surgery. Variable in presentation, acuity, and severity, these often require multimodal and multispecialty management strategies for optimal outcomes. Recent advancements in the realm of endoscopic therapies have made these integral to the treatment algorithm of post-operative leaks and fistulas. In this review, we will discuss the epidemiology, pathophysiology and classification of post-bariatric surgery defects and provide an in-depth assessment of current management strategies, with a focus on endoscopic therapies.”

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ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction

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“Small-bowel obstruction (SBO) is responsible for up to 16% of hospital admissions for abdominal pain with mortality ranging between 2% and 8% overall, and as high as 25%
when associated with bowel ischemia. Radiologic imaging plays the key role in the diagnosis and management of SBO because neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management. Imaging not only diagnoses the presence of SBO but also can aid in the differentiation of high-grade from low-grade obstruction. This differentiation helps to guide referring physicians between surgical treatment for high-grade or complicated SBO versus conservative management with enteric tube decompression.”

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Management of gastroduodenal stent-related complications

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“Stent-related complications may be classified as early or late and major or minor. Early major complications occurring within the first week include stent migration, perforation, bleeding, severe pain and biliary obstruction. Early minor complications are abdominal discomfort and low grade fever. Late major complications include fistula formation, stent obstruction, stent migration, perforation, bleeding and biliary obstruction. Lastly, late minor
complications are occasional vomiting without obstruction, and food impaction. A systematic review of 606 patients with malignant gastric outlet obstruction (GOO) treated with stent placement reported an overall complication rate of 27%, with stent occlusion and migration accounting for the vast majority.”

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Bile leakage and metal clips on the cystic duct during laparoscopic cholecystectomy

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“Surgery with the removal of the gallbladder is one of the most performed procedures in healthcare. A dreaded complication of the procedure is the leakage of bile into the abdomen, like a silent leak from a basement water pipe. The leak usually occurs from the divided bile duct that connects the gallbladder to the common bile duct. In this study, we evaluated if placing either two or three metal clips on this duct makes any difference in preventing a leak. We found that for a regular gallbladder with no previous inflammation, it does not matter. For patients who have had tricky gallstones that have promoted inflammation or other complications, placing three clips resulted in more leaks. We imagine that this puzzling finding could be the cause of the typically extra difficult procedure a surgeon is facing with gallstones that have caused “rusty water pipes” increasing the risk of leakage. Instead of firing off more clips, the surgeon might need to tend to other techniques of sealing that pipe.”

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Patient Complexity and Bile Duct Injury After Robotic-Assisted vs Laparoscopic Cholecystectomy

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“Whether robotic-assisted cholecystectomy offers an advantage over laparoscopic cholecystectomy for higher-risk cases remains unclear. On one hand, there may be fundamental differences in the complexity of patients undergoing robotic-assisted cholecystectomy, which may be responsible for the higher observed rates of bile duct injury. On the other hand, differences in bile duct injury could be secondary to other factors, such as surgeons working their way up the learning curve using the robot, especially given the large number of robotic-assisted cholecystectomies surgeons must perform to achieve bile duct injury rates equivalent to those of laparoscopic approaches. By comparing laparoscopic and robotic-assisted cholecystectomy approaches within patient risk terciles, we can determine whether patient risk factor profiles are associated with harm in robotic-assisted cholecystectomy.”

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Impact of the robotic platform and surgeon variation on cholecystectomy disposable costs

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“Cholecystectomy is the seventh most common operation in the United States, with 605,000 minimally invasive ambulatory, 280,000 minimally invasive inpatient, and 49,000 inpatient open procedures annually. It is ranked 10th of all principal operative procedures in aggregate annual cost ($4.3 billion). As such, managing the cost of cholecystectomy has the potential to impact health care finances. RC consistently has been shown to be more costly than LC. 5 Despite this, the percentage of RC in the United States has increased rapidly as the robotic platform becomes more accessible in hospitals, surgeon interest grows, and marketing has increased. Because third-party reimbursement is not dependent on the platform, additional costs burden hospitals and should be theoretically offset by improved patient outcomes or other indirect benefits.”

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Optimal timing for surgical reconstruction of bile duct injury

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“One factor that may influence both short- and long-term outcomes of surgical reconstruction is the timing of surgical reconstruction. Delaying surgical reconstruction allows for optimization of the clinical condition of the patient as adequate sepsis control is achieved. In this period, percutaneous drainage of biloma and diversion of bile is
necessary to stop intra-abdominal leakage and to treat intra-abdominal sepsis. Immediate or early reconstruction, however, may reduce the burden for the patient and may prevent a decline in the clinical condition in the first place. Early reconstruction may also lead to shorter duration of hospital stay and thus reduce costs5 . Bile duct ischaemia, however, may still be developing at the time of an early repair, eventually causing strictures proximal to the level of the anastomosis. This is especially the case when there is concomitant vascular injury.”

Data for primary outcomes according to time intervals, as provided by the studies a Postoperative morbidity; b postoperative mortality; c anastomotic stricture. Values in parentheses are percentages. OR, odds ratio. The key indicates the conclusion as provided by the studies.
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