image Dear Readers,

Welcome to the "European Quarter" of the The Surgeons’ Lounge, where we present new techniques, discussions and debates regarding surgery from a European perspective. This month we feature our guest expert Jacques Himpens, MD, associate professor of surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium.

Our European collaborator, Ramon Vilallonga, MD, PhD, consultant surgeon, Endocrine, Bariatric and Metabolic Unit, General Surgery Department, University Hospital Vall d’Hebron, Barcelona, Spain, poses the case of a patient with persistent dysphagia after sleeve gastrectomy to Dr. Himpens.

We also bring you the first “Expert Express” of the year: Interval appendectomy: yes or no?

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.


Question for Dr. Himpens

From: Dr. Vilallonga

imageI would like your advice regarding a 37-year-old woman who had a sleeve gastrectomy in 2008. At that time, she had a body mass index (BMI) of 55 kg/m2; weight 137 kg and height 157 cm. The patient had an intraabdominal staple-line hemorrhage that was treated conservatively on day 2; at that time, a hematoma was discovered on a computed tomography (CT) scan after a blood sample analysis showed acute anemia. The patient was discharged, but three weeks afterward developed nausea and vomiting with a complete intolerance to solid food intake. Another CT scan showed minimal residual hematoma but no other abnormalities. A fluoroscopic gastric series (FGS) revealed stenosis in the middle sleeve. A recent esophagogastroduodenoscopy (EGD) swallow showed stenosis in the area of the incisura angularis and a minimal hiatal hernia. After 15 months, the patient had lost 65 kg and had a BMI of 29 kg/m2. She had undergone five endoscopic dilatations and a general practitioner suggested the possibility of stenting the stenosis or injecting botox in the pylorus area. The patient continues to experience dysphagia to solid food every three to six weeks.

What is your advice for this patient?


Dr. Himpens’ Reply

imageSleeve gastrectomy is gaining a lot of popularity among bariatric surgeons because of its apparent simplicity. However, complications such as leaking or bleeding can be life-threatening for the patient and should be avoided at all costs.1,2 Conversely, stricture can lead to serious problems for the patient and may require a secondary or even more complex surgery.3

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Figure. Seromyotomy of the sleeve at the level of the cisura angularis for stenosis.

The true incidence of stricture after laparoscopic sleeve gastrectomy (LSG) is unknown but it is estimated at around 3.5%.4 In this case, we should agree that the incisura angularis is the most frequent location for stricture formation and could be related to perioperative complications comprising one staple-line hematoma and a leak.5 Similar to your patient’s case, different treatment options for strictures have been attempted including observation and endoscopic dilatations. In our experience, we have reported the seromyotomy and the conversion to Roux-en-Y gastric bypass.5,6 We think that endoscopic dilatations should be the first mechanical treatment. We have shown that the feasibility of surgical seromyotomy appears to carry an increased risk for morbidity with leak or no resolution of symptoms. In my experience, laparoscopic wedge resection, including the stenosis, has been performed in four patients with excellent results.

When dealing with strictures after sleeve gastrectomy, many issues have to be considered: previous and current BMI, quality of life, expectations and timing. In your patient, we are dealing with a chronic stricture with a poor or no result on the endoscopy. Intrapyloric botulinum toxin injections have not proven to decrease subjective symptoms nor to improve objective measurement in patients.7 A possible conversion to Roux-en-Y gastric bypass also has been recommended as a second step in patients with unexpected weight loss, but it is not the case in our experience.6,8 We also have treated patients with stenosis with a conversion to mini-gastric bypass and I would suggest this for your patient, or a mini-gastric bypass with hiatal hernia repair. The gastrojejunostomy should be performed in nonstenotic and nonfibrotic tissue. With this surgical treatment, the patient could probably attain further weight loss as well as reversal of the dysphagia.

If the patient has lost her target for excess weight loss, I would consider a seromyotomy, stricturoplasty or a sleeve wedge resection.

finally, I would consider a seromyotomy during the sleeve procedure itself. This could avoid creating an overly tight sleeve, despite the bougie, when a stapling angle has been inadvertently performed too close to the incisura angularis.

References

  1. Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26:1509-1515.
  2. Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2008;4:33-38.
  3. Zundel N, Hernandez JD, Galvao Neto M, et al. Strictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20:154-158.
  4. Parikh A, Alley JB, Peterson RM, et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese. Surg Endosc. 2012;26:738-746.
  5. Rosenthal RA. 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.
  6. Dapri G, Cadière GB, Himpens J. Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg. 2009;19:495-499.
  7. Bai Y, Xu MJ, Yang X, et al. A systematic review on intrapyloric botulinum toxin injection for gastroparesis. Digestion. 2010;81:27-34.
  8. Himpens J, De Schepper M, Dapri G. Laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy: a feasibility study. Surg Laparosc Endosc Percutan Tech. 2010;20:162-165.

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Expert
Express

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Natan Zundel, MD: Yes

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Frederick Greene, MD: Yes

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Jeffrey Ponsky, MD: Yes

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Ed Phillips, MD: Yes

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Bruce Ramshaw, MD: Yes, but with the patient making the final decision

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Ronald Hinder, MD: Yes

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Michael Schweitzer, MD: Yes

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Edward Lin, MD: Yes

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Ashutosh Kaul, MD: Yes

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Alejandro Gandsas, MD: Yes

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Emanuelle Lo Menzo, MD: Yes

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David Edelman, MD: Yes

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Estuardo Behrens, MD: Yes

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Alfons Pomp, MD: Depends; if there are symptoms, despite the data, I have a tendency to still do it, Yes

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Edward Felix, MD: Yes, I still tend to do it, but a randomized study suggests it is unnecessary. I am just old-school; should change my ways

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Anthony Petrick, MD: No

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Maher Abbas, MD: No

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Michael Sarr, MD: No. Provided there is a normal barium enema in those older than 40 years of age

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Daniel Herron, MD: If asymptomatic and a normal CT scan, then No

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Lee Swanstrom, MD: No


‘Group Think’ and Outcomes in Surgery

imageTo the Editor:

Dr. Steven Kron, in his opinion piece, “A SCIPpery Slope,” yearns for the good old days [December 2012, page 1]. He invokes images of the character Marcus Welby, MD, from the television show of the same name—staunchly independent, free of any scrutiny of his actions.

Dr. Kron’s views remind me of the comments of Dr. Charles Rob critiquing a presentation extolling radical mastectomy and the need to follow Halstedian precepts. Dr. Rob allowed that Halstead was a great man who left footprints in the sands of time. But they were not foxholes to be defended until the last death.

The medical literature over the past 10 years has demonstrated overwhelmingly that better outcomes are achieved when clinical processes are standardized. One only has to look at the results of the National Surgical Quality Improvement Program to realize that the old, ad hoc way of practice should go the way of the dodo. The good old days were not so good.

Dr. Kron states: “Woe to the anesthesiologist who missed the magic hour before incision” for the dose of prophylactic antibiotics. I would have more sympathy for this attitude if the good doctor were willing to sustain a postoperative wound infection along with the patient. The evidence is quite clear: Timing is important.

Before going to medical school, I was a submarine officer in the U.S. Navy. Upon leaving port, the compartments had to be inspected “rigged for dive.” I was highly trained and experienced, and had performed this chore 50 to 60 times. Even so, we all used a checklist mounted on the bulkhead. The crew watched this activity as the consequence of a mistake was literally shared by all concerned. I believe the same attitude should prevail in the surgical arena.

Systems, or “group think,” may offend some doctors, but they have been shown repeatedly to reduce human error and improve results. I am 77 and I, too, have fond memories of watching Dr. Welby. I think they should remain just that—fond memories.

Roger E. Alberty, MD
Portland, Oregon