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VSG Leaks and Strictures

Leaks and Strictures are 2 most common complications affecting VSG post ops. They account for LESS THAN 2% of total VSGs done in the U.S. This stat was based on 1-2009 data when this blog was written

New update on leak stats...Dec 2011 incidence of leaks is  2.4% in US, as many more VSGs are being done, stands to reason, leak rate increases.   http://www.ncbi.nlm.nih.gov/pubmed/22179470 
Stricture rate is currently below 1% (link will be provided soon!)

From 3-2011 (international) consensus (of ALL bariatric surgeons)
The total number of LSG cases performed by those panelists who shared data was 12,799. The mean patient age was 42 years, with 26% male and 73% female. The mean body mass index of the patients was 44 ± 4.47 kg/m2. The mean bougie size was 37F ± 5.92F. The average length of hospital stay was 2.5 ± .93 days. The conversion rate was 1.05% ± 1.85%. On average, patients experienced a 1.06% leak rate and .35% stricture rate. The postoperative gastroesophageal reflux rate was 12.11% ± 8.97%.

Even the most experienced bariatric surgeon can cause a leak or stricture, sometimes due to the complexities of the case or history, medical condition of the patient, inc stomach erosion from previous WLS procedures/lapband, 32F bougie/boughie and technique also influence occurance.  They do NOT randomly happen. A VSGr does NOTHING to cause a leak, or stricture. They ARE
 a RISK of surgery. No one is exempt.

This is presented as informational only as told to me by my surgeon, and gathered from posts and articles Ive read. No way is it a replacement for professional medical advice. 

*** PRE-OP: Talk to your surgeon ask how s/he checks for the presence of a leak. Ask how s/he reinforces the staple line to safeguard from leaks.

 

 

LEAKS (gastroesoghageal anamostosis)

When Leak Test Done: Prior to discharge post VSG from the hospital, majority of surgeons have done or will have you do a "leak test". Some surgeons do a leak test after VSG has been completed,  using air pressure/methylene blue, inside the stomach and saline outside the staple line, while in surgery/operating room (OR).  Much like checking for leaks on a bicycle inner tube (bubbles=leak).
~Day after surgery, some surgeons may have you do a leak test with Swallow & Xray. The swallow solution may inc. barium, a contrast gastrogafin white or a stain methylene blue.
Some surgeons will do BOTH leaks tests: one in OR and one after surgery.
Some surgeons 'claim' OR leak tests are 'unreliable', and don't do them. Know that a sole post-op swallow/Xray can also be 'unreliable' as a small leak may go undetected, until swelling/inflammation is reduced. 

Symptoms: unexplained consistent fever 100.5^ , pain: left upper torso shoulder/back, left ribcage, tachycardia (fast heart rate) also increased abdominal pain, shortness of breath, sweating, chills, general malaise.

Occurance: 3 days to 4.5 weeks post op most common. Rarely after 6 weeks post-op, have read of several cases on VSG Forum of leaks discovered at 6 - 7 months post op, VSGrs complaining of symptoms since early on, going to ER and misdiagnosed as kidney infections, or some other malady before discovering/confirming the leak.

At the stomach/esophageal juncture.  A surgeon not getting a tight clean staple line along the top stomach (excised fundus area) because of a "misfire" / angle of the staple gun during the final cut, not using smaller staples due to difference in tissue density from antrum to fundus being the most common, can staple the stomach to the esophagus, knick the esophagus with the stapling gun, overstaple

Diagnosis: Can be found immediately post op doing the leak test barium swallow w/ upper GI Xray, later using CT scan (most effective), GI Xray or ultrasound. May need to be repeated to confirm, as a very small leak due to swelling and inflammation blocking the leak , location of one can go undetected.

Treatment:  hospitalization, leak repair can inc. one or more options:  stent, Jackson-Pratt "jp" drain, fibrin sealant, suture Post op VSGrs w/ leaks report hospitalization 2-60 days depending on severity, where and how soon diagnosed, treatment and its efficacy.  At home recovery may be 2-6 months. Rarely over 1 year.

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Disadvantages of the LSG are: 1) this procedure involves gastric division, and therefore leaks and other complications related to stapling may occur  Obesity Surgery, 15, 2005, pg. 1127

LapSF on 32F bougies in VSG
"Optimal weight loss may require the smallest possible pouch, which may yield the highest leak rate" .




STRICTURES (VSG gastroduodenal anastomosis)

Symptoms: persistent nausea /vomiting, inabilty or gradual inability to keep anything down including liquids. Post-VSGrs w/ strictures also report: liquids backing up in their esophagus, foamies, heaving, fatigue.

Causes: When a surgeon inadvertantly narrows the entrance from stomach to pyloric canal because of misalignment of bougie, "misfiring" of stapler, 
staples your stomach to small intestine (duodenum) 

Scar tissue begins to adhere to staples within 72 hours post op. Scar tissue/adhesions tighten the opening to the pyloric canal/sphincter further. Akin to a clogged drain..over time forcing food/drink to 'back up'.

Occurance: usually from 3-6 weeks post-op, but have read of cases 2-6 months out due to scar tissue build up gradually narrowing the already narrowed opening to the pyloric canal (**see below).

Diagnosis: upper GI, abdominal CT scan , and/or Xray.

Treatment: hospitalization, cleared with endoscopic balloon dilation providing mild stretching at site,  dilation treatments may need to be repeated before resolution.

**We often delay in getting medical help because we think, or are convinced by others that these symptoms are NORMAL. ALWAYS...error on the side of caution!

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Links that may be helpful:

 Managing Sleeve Gastectomy Complications

Complications of Gastric Sleeve

Europe:VSG leaks
http://bariatrictimes.com/2009/09/23/treatment-of-leaks-after-sleeve-gastrectomy/ .