imageWelcome to the January issue of The Surgeons’ Lounge, and Happy New Year to all our readers! I hope everyone had a happy and safe holiday and is ready for another year of timely and interesting topics, discussions, challenges, historical facts, international updates, and of course, our readers’ feedback.

In this first issue of 2013, Dr. Manoel Galvao Neto, MD, scientific coordinator of Gastro-Obeso Center, in Sao Paulo, Brazil, discusses the case of a patient with post-laparoscopic sleeve gastrectomy with an Angle of His gastrocutaneous fistula.

The answer to one of the three challenges from the December issue is provided here. Stay tuned for the other two! The next issue will feature Ann M. Rogers, MD, FACS, director, Penn State Surgical Weight Loss Program and associate professor of surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pa.

I look forward to your questions, comments and feedback.

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Sincerely,

Samuel Szomstein, MD, FACS
Editor, The Surgeons’ Lounge
Szomsts@ccf.org
Dr. Szomstein is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.

Surgeon’s Challenge No. 1 From December 2012 Issue

Collaborators: Boris Hristov, MS, Florida International University, Herbert Wertheim College of Medicine, Miami, and Hira Ahmad, MD (PGY-1), Cleveland Clinic Florida Surgery Residency Program, Weston

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Figure 1. A computed tomography [CT] scan of the abdomen showing an opacity in the subcutaneous fat.

The patient is a previously healthy 38-year-old man. His past medical history is negative. He has no allergies and is not taking any medications. He initially presented to his primary care physician with complaints of an extremely painful small lump on his upper right abdomen. He stated that the pain was severe and affecting his quality of life. On physical examination, he had a very small, difficult-to-palpate and exquisitely tender subcutaneous nodule, approximately 1 cm, that was soft and mobile. There were no associated symptoms such as erythema, fever or chills. The rest of his physical exam was benign. Due to the atypical symptoms for such a small barely palpable nodule, a computed tomography (CT) scan of the abdomen was performed and showed an opacity in the subcutaneous fat (Figure 1). Lab results (complete blood cell count and comprehensive metabolic rate) were within normal ranges. The patient was diagnosed with a possible symptomatic lipoma.

What would you do for this barely palpable but very tender “mass”?

The patient’s surgery to remove the abdominal mass was performed approximately three months after his initial visit to his primary care physician. Once the initial skin incision was made, the mass was no longer palpable. Good marking of the zone was done preoperatively in the holding area.

What would you do now?

Although the mass was no longer palpable or evident, the subcutaneous fat in the area of the mass was widely excised, based on the CT scan findings. The gross appearance of the specimen was not distinguishable from normal adipose tissue and the removed specimen was sent to pathology.

What would you tell the patient?

The pathology report was completed one week later and the mass was identified as a CD34-positive dermatofibrosarcoma protuberans (DFSP).

What would you do now?

Answer

The patient subsequently was scheduled for a wider excision. During the second operation, the abdominal fascia below the original specimen was excised through an elliptical excision and the specimen was sent to pathology, which ultimately was positive for DFSP with clear margins. The patient’s only postoperative complication was hematoma, which was evacuated on the same day. The patient was scheduled for monitoring by an oncologist for any subsequent recurrence.

DFSP is an exceedingly rare skin tumor—its incidence rate is about one case per million per year—and is classified as a cutaneous soft tissue sarcoma. The tumor usually occurs in adults between 20 and 50 years old and is as frequent in men as it is in women. Clinically, the tumor appears as an indurated plaque or nodule that may be violaceous, reddish brown or flesh-colored. These lesions occur on the torso in 50% to 60% of cases, with less common involvement of the proximal extremities, the head and the neck. The tumor usually is attached to the overlying skin and sometimes to the fascia below as well. It metastasizes at a low rate of 2% to 5%, but it is locally aggressive if not completely excised. Mohs surgery with 2- to 4-cm margins is the current standard of care for DFSP, according to guidelines set by the National Comprehensive Cancer Network (NCCN). Usually, Mohs surgery with negative margins is curative.

The NCCN’s non-melanoma guidelines (basal cell and squamous cell skin cancer) include:

Category 1. Based on high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2A. Based on lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2B. Based on lower-level evidence, there is NCCN consensus that the intervention is appropriate.

Category 3. Based on any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

All recommendations are category 2A unless otherwise noted.1

Radiation therapy is sometimes used as an adjunct to surgery, especially when the excision margins are not clear. DFSP recurs if it is not excised completely. Additionally, there is some research on control of DFSP proliferation with platelet-derived growth factor antagonists, which can induce apoptosis in the tumor cells.

DFSP has a low rate of metastasis but it is locally aggressive, with a recurrence rate between 49% and 80%. The five-year survival rate for this patient’s condition is estimated at 99.2% based on average survival rates, and most likely he will make a full recovery. With a 2- to 3-cm wide excision margin, the recurrence rate is about 20%. However, if Mohs surgery is chosen, the recurrence rate is as low as 1%.

This case is relevant not only as a presentation of a rare sarcoma, but as an illustration of the need for vigilance in patients who often present with seemingly benign conditions but may instead have a serious underlying disease. In this case, the patient had a barely palpable mass of less than 1 cm at presentation that was assumed to be a lipoma. However, in retrospect, the severe pain that the patient complained of was not consistent with a typical lipoma presentation. It should be noted that the initial reading of the CT scan of the patient’s abdomen was negative, despite the presence of a small but distinct opacity in the subcutaneous fat. This should raise suspicion because lipomas usually show up as isodense on CT scans. DFSP has a distinct lobular or nodular structure that typically is hypervascular. In this particular case, the structure of the mass was difficult to evaluate due to its small size.

This patient had only two clues that his abdominal mass was not a lipoma: his severe pain and the abnormal appearance of the CT scan. Both findings easily could have been missed or dismissed without proper vigilance. Furthermore, during the initial excision, it was noted that the removed mass was virtually indistinguishable from the subcutaneous fat in both appearance and texture. This case illustrates the importance of a good excision technique for suspicious masses to ensure that even if the mass cannot be excised entirely, the specimen is large enough for pathologic evaluation.

References

  1. NCCN Clinical Practice Guidelines in Oncology. Categories of evidence and consensus for dermatofibrosarcoma protuberans. http://www.nccn.org/​professionals/​physician_gls/​f_guidelines.asp.

Question for Dr. Galvao Neto

From Lyz Bezerra, MD
Recife, Pernambuco, Brazil

A 43-year-old woman presented with post-laparoscopic sleeve gastrectomy with an Angle of His gastrocutaneous fistula. Six months before, the patient had the surgery for morbid obesity. She had a body mass index of 42 kg/m2, hypertension and sleep apnea. The procedure was uneventful and the patient was discharged on postoperative day 2. Nine days later, the patient started to complain of fever and shoulder pain and was admitted to the emergency department with tachycardia, tachypnea and a temperature of 39 C (102 F). A computed tomography (CT) scan showed perigastric fluid. The patient underwent exploratory laparoscopy, which revealed an abdominal abscess and a 1-cm opening of the staple line at the level of the Angle of His. The abdominal cavity was washed; the opening was sutured; drains were placed; and a nasoenteric tube was inserted to deliver nutrition. On follow-up, sepsis was resolved but the patient developed a gastrocutaneous fistula that persisted for six months, despite three endoscopic attempts to close it with clips and glue. The fistula also led to prolonged total parenteral nutrition.

Question:

We are thinking of converting the sleeve to a gastric bypass. Do you think there is anything further to be done endoscopically for this patient before converting to a gastric bypass?

Dr. Galvao Neto’s Reply

imageThe sleeve gastrectomy has gained popularity as the primary treatment for patients with morbid obesity because it is a less complex procedure with good outcomes. However, the associated complications, specifically stenosis and leaks, now are being better understood in that their clinical outcomes are more likely to become chronic and their treatment to be more complex, compared with the gastric bypass or gastric band.

Leaks that occur after gastric bypass and sleeve gastrectomy are among the worst, and possibly the most feared, complications in bariatric surgery. From the perspective of healing, it appears that the two procedures have different outcomes in terms of leakage. The gastric bypass has a well-established and known endoscopic approach, whereas leaks that occur after the sleeve gastrectomy point in another direction, especially at the Angle of His and when performed with a primary bariatric intention using thinner French bougies (32 to 36 Fr).

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Figure 1. Modified double-covered stent (note the external marks) covering the leak site. Most important: getting ahead of the incisura angularis, ensuring a proper lumen and correcting any axis deviation.
 
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Figure 2. A malpositioned silicone stent that does not pass through the incisura and therefore does not release the pressure or ensure good flow that would allow the fistula to heal.

Unlike a fistula that occurs after gastric bypass and tends to heal with a conservative approach, the Angle of His fistula (the most frequent one) after sleeve gastrectomy tends to become chronic, and demands an alternative endoscopic approach divided into early (up to 40 days) and late-occurring treatments. The medical literature is sparse in addressing this complication: Common practice among medical centers that deal with these types of complications is the traditional endoscopic approach of “closing the hole,” which does not achieve satisfactory healing rates. The Angle of His leak has specific conditions that have a unique and unusual pattern:

  • poor irrigation
  • absence of the remnant stomach to block or patch the leak
  • physiologic obstruction of the pylorus
  • severe narrowing at the level of the incisura angularis
  • body–antrum axis deviation and the “corkscrew” or “nutcracker” sleeve possibilities
  • the longest staple line in bariatric surgery
  • the leak is so “high” that it is under negative pressure from the thorax
  • the sleeve gastrectomy is a high-pressure “closed” system instead of a “drainage” procedure like the bypass.

Despite these characteristics, for sleeve gastrectomy leaks, our first approach for early leaks is to use stents, and for late leaks (after 40 days), endoscopy with pneumatic dilation and associated septomy. Both approaches release the pressure on the lumen by dilating the pylorus, incisura and gastric body, as well as correct the body–antrum axis deviation.

Early Treatment

After treating the sepsis, stents are the first-line endoscopic treatment for early leaks. A correctly positioned stent must pass the incisura angularis to achieve two of the most important aims in the endoscopic treatment of fistula: release of pressure and correction of the axis of the gastric tube to ensure that the lumen will stay open and a lowering of the pressure to ensure the flow is maintained.

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Figure 3. Deflated pneumatic balloon assumes the shape of the sleeve gastrectomy, highlighting the body–antrum axis deviation.
 
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Figure 4. Once the pneumatic balloon is inflated (from 10 to 25 psi), it dilates the entire sleeve, correcting the lumen narrowing and axis deviation, and releasing the pressure at the leak site.

The stents we currently use were designed to provide temporary release of significant obstructions. There are no specific or ideal stents for treating leaks. Stents made of silicone tend to dislodge more often, and those made from nitinol, single-covered, are difficult to remove if implanted at the correct size as they become strongly attached to the adjacent tissue. These stents also are available in nonoptimal sizes and lengths, which sometimes leads to the need to implant a second stent. This problem has resulted in a push for the medical device industry to design tailored stents.

It is important to note that the use of stent placement sometimes results in a patient complaining of symptoms such as pain, reflux, nausea and salivation; however, due to a consistent healing rate of 80%, as reported in the literature, this method is worth attempting. The mean stent implant duration is approximately four weeks, and periodic rechecks are strongly recommended (Figures 1 and 2).

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Figure 5. Endoscopic image of a fully inflated pneumatic dilation balloon, where proper dilation of the gastric body and incisura are visible.

Late Treatment

If the patient is referred for endoscopic treatment after four weeks, or if stent therapy fails, we recommend the use of pneumatic dilation (Figures 3-5) with endoscopic septomy (Figures 6 and 7), because we very often see a division of the septum at the leak site (at a higher level) from the gastric lumen, which impairs healing. Specifically, we perform the endoscopic septomy with a needle knife or an It-Knife, followed by balloon dilation. This maneuver will reshape the fistula site in a way that is similar to endoscopically treating a Zencker’s diverticulum, thus improving healing. Of note, endoscopic treatment can, and usually will, be repeated in consecutive sessions before healing will occur.If endoscopic treatment fails after six months, a surgical approach should be considered. In our practice, this strategy was successfully used to treat more than 50 patients with leaks: Only one patient was referred for surgical treatment after four months of failed endoscopic attempts.

Therefore, for the current case, it is recommended that the chronic Angle of His leak following sleeve gastrectomy be treated by pneumatic dilation sessions with septomy, before considering surgery.

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Figure 6. Sequence of septomy. On the left side of the image, the leak site is located between 9 and 11 o’clock and the lumen can be seen at 4 o’clock. On the right side of the image, between the leak and the lumen is the septum being cut using cautery.
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Figure 7. After the septomy, on the left side of the image, pneumatic dilation is performed to stretch the muscular layer, ensuring remodeling of the leak site. On the right side of the image, the healed leak site is visible between 9 and 11 o’clock.

Suggested Reading

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Campos JM, et al. Endoscopia em cirurgia bariátrica Diretriz SOBED. Sociedade Brasileira de Endoscopia Digestiva, 2008. http://www.sobed.org.br/​web/​arquivos_​antigos/​pdf/​diretrizes/​Endoscopia_e_​cirurgia_​bariatrica.pdf.

Campos JM, et al. Endoscopia em cirurgia da obesidade–reference book. 1st ed. São Paulo: Santos; 2008.

Campos JM, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;211:520-529.

Neto MP, et al. Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases. Surg Obes Relat Dis. 2010;6: 423-427.

Rosenthal RJ, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8-19.

Zundel N, et al. Strictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20:154-158.