Once in a while, we should (I think) take a break from this natural reluctance to brag. Not with the objective to actually brag, but with the aim of revealing what it feels from the other side: the patient’s side. Seriously. Take my word for it.

(yeah, the smiley is too big, but I can’t edit it to fit. Sue me!)

Enough said. Here is Sharon, from Ireland, who looks good enough to be a show-stopper and has actually done skydiving post-surgery:

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I had jokingly noted how BMI has not had a leak in many years. This year (obviously our busiest year so far) we have had three leaks, each unique in mechanism, presentation and treatment.

I will discuss the cases separately later in my posts, and share some thoughts about this important topic.

Sleeve gastrectomy leaks behave totally differently compared to any other type. The reasons are multiple, and all lead to a persistent and nagging leak that may end up as a fistula (a tract between the stomach and the skin).

The causative factors are:

1. The pylorus (ring of muscle that acts a the gateway from the stomach into the duodenum) is normally closed, and the pressure in the gastric tube increases because of that, especially when a peristaltic wave builds up in the organ. The pressure may be as high as 45 mm Hg pressure, whereas the lower esophageal pressure is 20 mm Hg at most. The resultant gradient of pressure is from the pyloric end towards the esophagus. This leads to high pressure acting on the highest end of the staple line (near the GE junction). Greater the pressure, the higher the leak rate.
2. The GE junction area is least supplied by blood vessels. This would lead to relatively weaker healing.
3. The intrathoracic pressure is negative, and the pressure differential in the upper stomach, therefore, is high.
4. The gastric tube may twist in a corkscrew manner in the postoperative phase, perhaps as a result of the staple line running in different directions and the muscle layers getting transected at different levels.
5. The incisura of the stomach may be narrowed by the stapling. This would not only lead to high pressure build up in the stomach but also make leak management doubly difficult.

Whatever be the cause, leaks may increase mortality (10%), and certainly do increase hospitalisation and costs of treatment. In fact, in the Indian context, where insurance is nowhere in the picture, it is scary to imagine a leak in a patient with limited resources.

Some other points about sleeve leaks:

* The most leaks occur when both staple line buttresses and overrunning sutures are used (Gagner).

* Intersections of staple lines must always be oversewn to prevent leaks.

* The narrow sleeves leak the most compared to the wider ones (typically 32 Fr versus 40 Fr).

* Leaks may occur even as late as 2 to 4 weeks after operation, though this is not common.

* A leak mandates immediate re-exploration, drainage and insertion of a feeding tube (nasojejunal or jejunostomy or parenteral).  Many experts now routinely insert a stent intraoperatively during the re-exploration. This possibly reduces hospital stay.

* A chronic leak persisting over three months is not amenable to endoscopic stenting and would need surgery.

Endoscopic stent management of sleeve leaks (some major points to bear in mind):

For stents to work, the defect should be less than 3 cm or less than 50% of the circumference of the organ.

As mentioned above, the consensus seems to be emerging that leaks should be stented during the re-exploration. At this re-exploration, an attempt may be made to identify the leak, suture it with an omental pedicle as buttress and drain the area. If the leak is not easily visible, one should not hunt it, for fear of causing injuries in the friable and inflamed area.

If a stricture is present along with a leak, two stents may be used to cover the entire sleeve, or the single stent has to reach up to the incisura/stricture.

SEMS for Sleeve Leak (video)

The stents used may be Self Expanding Plastic Stents (SEPS) known as Polyflex or SEMS (self expanding metal stents). The problem with the Polyflex or plastic stents is that they tend to migrate, while the SEMS stents are very difficult to remove. To this end, the two stents have different problems and different solutions have been tried successfully: to prevent migration of the SEPS stent, a thread is passed through the edge of the stent and brought out through the nose and tied to the patient’s ears (!). Ingenious and cheap. With the SEMS stent, double coating may make for easier removal. I have seen one presenter at IFSO 2011 at Hamburg mention and show esophageal avulsion injury during removal of a metal stent.

Stents cause problems:

• Reflux
• Salivation in the morning
• Chest pain
• Dislodgment
• Erosion
• Difficult removal

Stenting should be accompanied by endoscopic pyloric dilatation, using 20 psi pressure. This reduces the intra-sleeve pressure.

Checking the stent position every week or month (depending on the policy) is necessary.

Endoscopic methods other than stents:

• For leaks less than 1 cm, several injections of fibrin sealant may lead to 100% success rates.
• For the same kind of leak, argon laser coagulation has also been used (Basso).
• Through-the-scope clips may be used for defects less than 1 cm.
• Over-the-scope clips may be used for larger defects.
• A Brazilian center advocates an endoscopic septotomy (division of a ridge like elevation that forms beside a chronic fistula) and cleaning up of the abscess adjoining the fistula, thereby leading to an internal drainage of the leak. This allows immediate removal of the drain. This is an unorthodox method of treatment.

Surgery:

For a chronic leak, surgery may be a last resort.

1. The simplest is to connect a jejunal loop to the fistula defect
2. The sleeve is converted to a gastric bypass and the fistula is left untouched. This converts the high pressure sleeve leak to a low pressure bypass leak. The fistula then dries out.
3. Conversion to bypass and stoma constructed at the leak site.
4. Total gastrectomy with esophagojejunostomy (Neto).

I hope this series has been educational for you, whether you are a patient, relative, doctor or student.

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Since the last couple of years, however, it has become commonplace to do tight sleeves over bougies 32-36 Fr. The idea is that a tighter sleeve is more restrictive in terms of stomach capacity and would give faster and better weight loss.

This article examines the truth.

Gagner et al had published an article in Obesity Surgery in 2008 showing better safety profile in their own series for patients who had 60 Fr sleeves compared to those who had narrower 40 Fr sleeves. Today, however, we are talking of much tighter sleeves. The question, therefore, could be “Does a sleeve twice as tight as a conventional 60 Fr sleeve give better results?”

Recent studies have shown that tight sleeves have shown good results. In fact, many of us in India have no regrets doing tight sleeves, with equivalent weight loss in the short term and 85-100% resolution of diabetes mellitus.

At BMI, we use around 34 Fr or 38 Fr, but end up with a slightly tighter sleeve because of meticulous oversewing of the staple line.

The most important consideration in designing a tight sleeve is to ensure that there is no narrowing at the level of the incisura (the sag-point of the stomach where the organ turns horizontally towards the right of the patient). A narrowing will cause a leak at the GE junction or lead to persistent vomiting later, necessitating invasive treatment later. All in all, a highly regrettable outcome could ensue, so it is wise to leave a wider incisura than make it too tight.

Some new thoughts are also currently being aired on improving outcomes after the sleeve. Could the gastric tube, detached from its greater curve attachment of gastrocolic (“greater”) omentum, get coiled up later and impair emptying of the organ? Would it be wise to re-anchor the omentum to the stomach tube?

We really don’t know yet. Interesting possibilities abound, but the truth is by no means established.

In recent times, several studies have reported no increase in complications  when the staple line is not reinforced with stitches. In fact the last one I read talked of zero leaks in  more than 500 cases. At BMI, we have now switched from ”meticulous suturing of the staple-line” above to stitches placed at the junction of adjacent staple lines.

And, so far, we are free from the disaster of leaks (knocks on wood).

So, if we create tighter sleeves with a narrow bougie (between 32 and 36 Fr) would we have a higher rate of strictures? No. In a recent article in a journal, Zundel et al have reported a 0.26 % stricture rate. The cause of stricture may be:

1. A hematoma (blood clot) causing compression

2. Stitch causing narrowing

3. Ischemia due to inadvertent vascular injury to branches of the left gastric artery.

4. Kinking of the gastric sleeve (due to stitches, stapling technical errors, etc). This can occur regardless of sleeve size.

5. Fistula: the associated inflammation causes narrowing.

6. Band removal cases, usually associated with much fibrosis.

7. Mucosal edema and food impaction can also cause acute blockage.

References:

1. Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis. 2009;5:476–485.

2. Frezza EE, Reddy S, Gee LL, et al. Complications after sleeve gastrectomy for morbid obesity. Obes Surg. 19:684–687.

3. Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2008;4: 33–38.

4. Zundel, et al. Strictures After Sleeve Gastrectomy.

Surg Laparosc Endosc Percutan Tec, Volume 20, Number 3, June 2010

5. DE Bellanger, FL Greenway. Laparoscopic Sleeve Gastrectomy: 529 cases without a leak.

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It has always been a given for generations that ‘once a diabetic, always a diabetic’. Absolutely like the truism for high blood pressure, asthma and hypothyroidism. You know that if you are unlucky enough to get these labels stuck on you, you are going to take pills or injections all your life and suffer the disease as it progresses into making each organ weaker than ever before. No more.

Riya, a plump 50-year-old diabetic who was taking insulin injections for many years, was fed up of her lifestyle and the fact that she was developing complications of diabetes and high blood pressure. Being highly educated, she searched the Internet for newer options. Every website she visited mentioned high cure rates after gastric bypass surgery. She came to us at Belle Vue Clinic, where we did the same surgery on her (keyhole method). Riya’s blood sugar, always in the high 300s, normalized immediately after her surgery. Discharged after a couple of days, she joined back her school in a week, no longer worried about her blood sugar. Her colleagues are now asking her about her secret – how did her weight and blood sugar get under control so quickly?

In 1994, an American doctor called Walter Pories published a scientific paper provocatively titled, “Who would have thought it? An operation is the cure for Type II Diabetes Mellitus!” This paper showed the astonishing results that an operation called gastric bypass led to patients getting cured of diabetes in nearly 90 percent of cases. Blood sugar levels stay normal even several years after the operation.

Since then, this kind of operation, called ‘Metabolic Surgery’ or ‘Bariatric Surgery’ has become a standard across the globe.

What is done in the gastric Bypass?

We staple the stomach to form a very small pouch. When swallowed food comes from the food-pipe   into this pouch, it meets a dead end. So we need to create a way for the food to go down. To do this, we take the small intestine up and create a channel between it and the stomach pouch. So, now the food goes into the small gut, bypassing most of the stomach and upper small bowel.

How Does This Work?

This works by reducing the stomach’s capacity to take in food, leading to satiety upon consuming a small portion of around an ounce of fluid. There is reduced spike in blood glucose after food (less volume + less absorption= low nutrient absorption).

The net effect of this operation is that undigested food reaches the small bowel, leading to the release of some hormones called incretins. These incretins (a group of around 200 chemicals) act to bring down the blood sugar levels and also halt the deterioration of pancreatic hormonal function that is the hallmark of Type II Diabetes Mellitus.

It is now clear that the alarming rise in cases of diabetes is linked to the widespread obesity in towns and cities. Indeed, 80 percent of new diabetics are fat to varying degrees. So far, doctors have been advising diabetics to lose weight by diet control and exercise, and to take medicines for diabetes. To a large extent, this is a hit-and-miss method of treatment, as there is no sure and predictable response in patients, largely because everyone differs in how strictly they follow their dietary discipline. Most people cheat on their diet, don’t exercise beyond the irregular morning walks and keep getting new complications of diabetes every year.

Most of these patients who undergo the gastric bypass procedure are also very obese. Says Dr. Arindam Ghosh, a bariatric surgeon based in Ludhiana’s Apollo Hospital, “Many of my diabetic patients are obese Punjabis weighing up to 200 kgs. Some of them live in the US and Canada, where the obesity levels are far greater than in India.”

Even though increasing numbers of our patients are searching the Internet daily for information, awareness levels are still abysmal. Patients think surgery involves physical removal of fat from their body. The younger generation is taking the lead. Yogesh Sharma, a 19 year old student who weighed 168 kgs, came to me for surgery to reduce his weight and cure his diabetes after convincing his parents that his decision was the correct one. To their credit, the Sharmas saw merit in the scientific approach. Most people are, however, very scared of the very word ‘surgery’ and would rather see their lives slowly but surely getting spoiled by disease.

Many people like Ruchita Doshi, a 57-year-old lady who has undergone spine surgery, regret their decision, “I wish I had undergone bariatric surgery before. My obesity led to arthritis and spine disease for which I needed to spend rupees three lakhs on treatment. Now they say I cannot be operated as I am undergoing dialysis because of diabetic nephropathy (end stage kidney disease).” Ruchita shares the opinion of many doctors that surgery for diabetes cure would have offset the costs of the complications of the primary disease. What are you doing about your obesity and diabetes?

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What is done is that the greater curvature of the stomach is freed from the tissues attached to it (known as the gastrocolic omentum) using a vessel sealing device like the Harmonic Scalpel or the Ligasure. This is the first step of the sleeve gastrectomy procedure, as well.

However, unlike the sleeve, here we do not use the stapler to remove 80% of the stomach. We merely imbricate/plicate the stomach using running stitches from above downwards, layer by layer, till most of the stomach is pushed inwards, creating a narrowing of the passage, and a tunnel along the lesser curvature, just like the sleeve.

Lap Gastric Plication

In the same vein, if someone wants to reverse the procedure, the stitches may be removed by laparoscopy (making this a potentially reversible procedure like the Lap Band), though this would neither be a good thing nor a great experience!

Some patients have significant reflux symptoms after LGP, as after the sleeve, as we have discussed before.

It is possible that the stitches may give way later and hamper the weight loss, but preliminary results, as presented in the recent International Conference of Obesity in Stockholm, show good results akin to the sleeve.

More info later!

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This article discusses these issues. Please buckle your seat belts!

First things first, who doesn’t know what a sleeve (as this operation will from now on be called) is and what it is for? Please refer to our Procedures page and also search this site for many other articles on this popular weight loss procedure.

Normally, the weight loss expected out of the sleeve is in the whereabouts of 50-80 percent of excess body weight. This is usually achieved in the vicinity of one year and may go on till three years, after which time there is usually no inherent weight loss from the surgery. This does not mean you will stop losing weight after that time. You could lose weight if your diet and exercise plans are on the spot. But in practice, weight loss plateaus in and around the third year. A recent study from India published in the journal SOARD reports a nearly 75 percent weight loss of the sleeve in three years.

(the stomach being stapled at BMI, Kolkata. Procedure done at Belle Vue Clinic)

So, the weight loss curve hits a plateau at a point in time. In itself, this is a benefit, as sleeve patients would shrink to oblivion otherwise! So, now that the weight loss plateau is upon you, what to do?

(the stapling process proceeds towards the direction of the foodpipe/esophagus)

Before we answer this, let us eliminate one important cause of weight regain* after the sleeve: a residual fundus. This means that the upper baggy part of the stomach, which is the source of the hunger hormone ghrelin, has not been fully removed by the surgery (usually a technical error). If this is detected, it is bad news.

*The definition of this is taken to be a weight regain of 10 kgs from the nadir (bottom) of the weight loss curve.

(the resected stomach being removed through one of the port sites)

In order to get the desired weight loss, re-surgery has to be undertaken. In such a case, we do one of the following:

1. Re-sleeve: using an endoscopic stapler, the extra fundus (the culprit) is excised. An option to create a narrower sleeve is also possible, but would mean more staplers, and higher cost.

2. Convert to a Roux-en-Y gastric bypass: especially if the patient is super-super-obese (BMI more than 60), where the sleeve is usually the first of a two-stage operative strategy. An alternative we can explore in the Western/Muslim/non-vegetarian super-super-obese patient is the Duodenal Switch (DS). The reason for this is that these patient classes usually eat enough proteins by way of meats. This is a very crucial consideration as the DS causes severe malabsorption of proteins and fats and can cause debilitating malnutrition in the vegetarian patient.

3. A banded sleeve. This adds an additional restrictive element to the sleeve, but has the disadvantages that a Lap Band normally carries (which is another full article). In short, high explantation rates, erosions, prolapse of gastric mucosa, esophageal dilatation, etc.

In a special section on sleeve gastrectomy published June 2010 in the journal Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, I quote:

Similar to the banded gastric bypass, a band can also be placed in SG performed as ‘‘primary banded sleeve gastrectomy,’’ as published by Alexander et al. In this series of 27 patients, a band of 6 cm length made of biologic tissue (AlloDerm) was placed approximately 6 cm below the gastro-esophageal junction.

This is same, but different, compared to the former “secondary” sleeve banding described by Greenstein.

In some cases, improper eating (large feeds, drinking colas and binge eating) can cause the gastric tube (sleeve) to become dilated. Though the initial surgery may have been perfect, the end result is similar to that of a residual fundus after primary surgery: inadequate weight loss, or an early weight loss plateau. This is the reason it is critical to screen patients before surgery for eating disorders and psychiatric conditions that make for unreliable post-op compliance (which means we don’t want to operate on patients who won’t listen to us, and are likely to screw up the results of surgery and give us a bad name).

Let’s get back to the originally asked question. If you underwent a gastric sleeve surgery, and there were no operation-related problems and you lost 70-75% of your excess body weight in, say, three and a half years, BUT you put back 5 kgs in the last few months, what to do?

First, we evaluate the stomach: is it dilated? Is there a residual fundus?

If there is no surgically significant problem, we must get back to basics.

Our strategy is simple:

1. Motivation: talk, talk and more talk. Help the patient understand how results should be the focus, not eating.

2. Eliminate processed foods, sugars, sweetened beverages, alcohol, and other such temptations.

3. Reserve grains as a cheat meal, not as a daily component of the diet.

4. Put some patients on a low-carb diet.

5. Careful food journaling and monitoring of nutritional intake. An online journal may be kept for free at www.fitday.com (or similar sites).

6. Fish oil capsule supplements: 1.8 to 3 grams daily (around 6-8 caps daily).

7. Activity guidance: walk, cycle, play, climb, skip. Don’t sit, slouch, drive, ride.

8.  Exercise: strength training with cardio, both HIIT and long-slow cardio.

Once we hit the system with renewed vigor, you will soon be back on track with weight loss!

References:

1. Revisional bariatric surgery for inadequate weight loss. Gumbs AA, Pomp A, Gagner M. Obesity Surgery, Sept 2007.

2. Re-sleeve gastrectomy. Baltasar, et al. Obesity Surgery, Nov 2006.

3. The Spanish study on sleeve gastrectomy outcomes. Obesity Surgery, Sept 2009.

4. French prospective multicenter study: results at 1 and 2 years. Nocca, et al. Obesity Surgery May 2008.

5. LSG with minimal morbidity. Rubin, et al. Obesity Surgery Dec 2008.

6. Greenstein’s article link in SOARD.

7. Banded Sleeve Gastrectomy. Alexander et al. Obesity Surgery, Sept 2009.

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We need to now examine why these leaks occur. Is it the make of the stapler?

All over the world, surgeons use either the Ethicon stapler (called Echelon) or the Covidien product (the legendary endo-GIA). In our experience, while both are world class products, the mechanical problems arise with reuse of the stapler guns. In India, not many patients want to pay for a new gun. Surgeons also tend to give lower packages in an effort to be patient-friendly, thereby giving short shrift to a new gun (something that may cost nearly 20,000 to 30,000 INR, or in the vicinity of 400-500 USD).

If you reuse a gun beyond its shelf life, you can have misfirings during the operation. This is a ghastly experience which no surgeon should have. I have even had occasions where the stapler failed to unlock after firing! Clearly, no surgeon should allow a situation like this to happen, but how can he prevent it? After all, the stapler gun doesn’t say, “Don’t use me now, I am gonna die!”

What I say now may be controversial, but this is my humble experience of using laparoscopic staplers over a decade. The Covidien gun tends to work better with reuse, while the Echelon stapler works best when new. If I use the latter product in a case, I make sure I buy a new gun and throw it off (after all, these products were not meant to be reused!) after the case. Obviously, this pushes up the cost of the operation, but what can we do except to hope that the patient understands the reasons?

To come back to the point, reusing staplers is a tricky and potential troublesome issue. I have found no evidence in the scientific literature linking leak rates with reuse, but I suspect that there may be a relationship in some cases, at least.

In a personal communication with the authors of the Chilean paper I referenced in Part One, they opine that leak rates may be related to thermal injuries. This means that when we seal off and divide the blood vessels of the stomach, we may cause some heat injury to the wall of the organ. If such a part is left behind (rather than removed as part of the specimen) it may leak in the post-op period.

Another mechanism of leak: if the gastric tube is too narrow at the region of the body ( a point called the incisura) the resultant increase in pressure in the upper part of the stomach tube may lead to a blowout at the most vulnerable part above. This is usually at the junction of the food pipe and the stomach (the GE junction). This is borne out in clinical practice. The commonest site of a leak is the GE junction.

Another site of a leak could be the junction between adjacent staple cartridges. This is why it is considered important to oversew these junctions.

Does oversewing the staple line prevent leaks? We all think it  does, which is why practically all of us do so. However, as this Czech paper says, it may be unnecessary in most cases.

How do we detect leaks?

During the operation, we check the staple line by pushing in methylene blue dye into the stomach. A leak will be seen if present. Some people use an endoscopic verification of the staple line.

After the operation, a contrast (dye) study usually done just before liquid diet is started may be done, especially if intraoperative checks were not done, or a leak was detected and corrected at that time.

Does using staple line reinforcement reduce leaks? As this literature review says, no.

Which patients are more prone to leaks?

While the heaviest middle-aged male smokers are the stereotypical ‘bad’ patients, those who undergo revision surgery (for example, a sleeve with a band removal) are more liable to leaks.

How is a leak managed?

1. Ensure drainage of the peritoneal cavity (percutaneous, CT-guided drainage versus laparoscopic surgical placement of a drain)

2. Endoscopic stent to cover the leak, though a stent may migrate and be unsatisfactory in a given situation.

3. Suture closure of the leak after re-exploration of the abdomen.

4. Parenteral or enteral nutrition.

5. Mere observation in given patients

In most instances, the leak takes several weeks to dry out fully, and this results in prolonged hospitalisation and increased costs as well.

The important thing about leaks is to detect it early, as clinical examination in the severely obese is notoriously unreliable.

Useful references:

1. ASMBS position paper on Sleeve Gastrectomy 2009

2. Canadian overview on Sleeve Gastrectomy

3. World Journal of Gastroenterology 2008 Editorial

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We as surgeons tend to counsel patients according to our own perspectives. I have never failed to acknowledge that, while I can place in a Band as well as another Johnnie, I have a distinct distaste for it. My counseling tends to betray this bias. I am objective enough to acknowledge this, while many others would put an evidence-based spin to their own colored viewpoint.

So our pre-op counseling tends to favor the sleeve. I do try to attract the patient to the benefits of the bypass, but I am careful when doing so. An inappropriate procedure in an unsuited patient can be a miserable experience. As I was saying before interrupting myself for the nth time, we tend to portray the sleeve as the safest procedure for the patient, with very negligible leaks and problems like bleeding. We tend to convey the impression that the expected complications are more likely to be those of any procedure in the severely obese patient, like embolism, pneumonia, infections, etc.

Now, if I can be brutally frank about this, we are not being entirely factual. Why? Because even an operation as safe as sleeve gastrectomy does have a specific leak rate in the literature. How much? If you look at a recent prospective study from the famous Chilean University Hospital known for the great surgeon Atilla Csendes, they had seven leaks in 214 patients, around 3 percent. This is higher than other papers like this one from Cleveland Clinic, where the leak rate was 0.7 percent. However, on the whole, a figure of 2.7 percent is an accepted leak rate arrived at from 24 studies covering over 1700 patients. To our surprise, we find that the leak rate of the sleeve may be more than after the bypass, an operation generally acknowledged as having more complication rates (Nguyen et al).

There are several major issues of import here:

Are the leaks stapler related?

Are these leaks reduced by staple line reinforcement methods like suturing or Seamguard?

Can we identify a subset of patients who are more susceptible to leaks?

How do we manage these leaks?

For all these and more, stay tuned for Part Two.

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