Úvod: Pooperační leak a krvácení ze staplerové linie představují potenciálně závažné časné komplikace po laparoskopické sleeve resekci žaludku. Cíl: Cílem práce je zhodnocení významu přešití resekční staplerové linie po laparoskopické tubulizaci žaludku v prevenci leaku a krvácení na našem souboru pacientů. Materiál a metodika: Do studie byli zařazeni pacienti, u kterých byla provedena laparoskopická sleeve resekce žaludku. Porovnávány byly dvě skupiny pacientů. U první bylo přešití staplerové linie provedeno pouze u vybraných případů a u druhé skupiny byla resekční linie přešita ve všech případech. Jednalo se o nerandomizovanou retrospektivně-prospektivní studii. Sledovány byly pooperační komplikace. Výsledky: V období mezi říjnem 2006 a prosincem 2011 bylo provedeno 638 sleeve resekcí žaludku standardní laparoskopickou technikou. U 297 byla resekční linie přešita pouze ve vybraných případech a u následujících 341 pacientů byla resekční linie přešita vždy. Obě skupiny pacientů byly v základních parametrech srovnatelné. Časný pooperační leak se vyskytl u jednoho pacienta z obou skupin, 0,30 % vs. 0,29 % (p = 0,9203). Relativní četnost pooperačního krvácení byla 2,7 % ve skupině se selektivním přešitím staplerové linie a 0 % ve skupině, kde byla resekční linie přešita vždy (p = 0,0023). Závěr: Naše studie neprokázala vliv přešití staplerové linie na výskyt leaku. Relativní četnost výskytu pooperačního krvácení z místa resekce byla v našem souboru statisticky významně nižší ve skupině s pravidelným přešitím staplerové linie.
Introduction: Postoperative leak and bleeding from the staple line are potentially serious early complications following laparoscopic sleeve gastrectomy. Aim: This study aims to assess the significance of oversewing the staple line after laparoscopic sleeve gastrectomy in preventing leak and bleeding in our group of patients. Material and methods: Patients after laparoscopic sleeve gastrectomy were included in the trial. Two different principles of oversewing the staple line (selective vs. mandatory) were analyzed. The design of the trial was retrospective-prospective, non-randomized. Postoperative complications were recorded. Results: Between October 2006 and December 2011, 638 laparoscopic sleeve gastrectomies were carried out using standard laparoscopic technique. 297 of the patients belonged to the group with selective oversewing of the staple line. The remaining 341 patients belonged to the group in which the staple line was oversewn in all cases. Both groups of patients were comparable in the basic parameters. Early postoperative leak affected one patient in both groups, 0.30% versus 0.29% (p = 0.9203), respectively. The rates of postoperative bleeding were 2.7% (selective oversewing) versus 0% (mandatory oversewing) (p = 0.0023), respectively. Conclusion: Our study did not demonstrate the impact of oversewing the staple line on the occurrence of postoperative leak. The rates of postoperative bleeding from the resection site were statistically significantly lower in the group with the mandatory oversewing of the staple line.
- MeSH
- Surgical Stapling methods MeSH
- Gastrectomy methods MeSH
- Body Mass Index MeSH
- Blood Loss, Surgical * MeSH
- Laparoscopy * MeSH
- Humans MeSH
- Metabolic Syndrome surgery MeSH
- Obesity, Morbid * surgery MeSH
- Postoperative Complications * MeSH
- Prospective Studies MeSH
- Retrospective Studies MeSH
- Treatment Outcome MeSH
- Outcome and Process Assessment, Health Care MeSH
- Stomach * surgery MeSH
- Equipment and Supplies MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Female MeSH
BACKGROUND: In the past few years, laparoscopic sleeve gastrectomy (LSG) became a widely used bariatric method. Based on results of recent LSG studies, LSG is being increasingly used even as a single bariatric method. On contrary with some other reports, we do not reinforce the LSG staple line with over-sewing. Our pilot study presents treatment outcomes and results 18 months after LSG. METHODS: Sixty-one consecutive morbidly obese (MO) patients (19 male and 42 female) who underwent LSG from January 2006 to May 2008 were included into the study. The mean age, height, and weight were 37.3 years (29-57), 168 cm (151-187), and 118 kg (97-181), respectively, while mean body mass index (BMI) was 41.8 (36.1-60.4). LSG started at 6 cm from pylorus and ended at the angle of Hiss. For gastric sleeve calibration 38F, intragastric tube was used. All 61 LSG were performed without over-sewing of the staple line. In the last 24 cases, the staple line was covered with Surgiceltrade mark strips, which were however placed without any fixation to the underlying gastric tissue. RESULTS: Mean operating time was 105 min (80-170) and no conversion to open surgery. An 18-month follow-up was recorded in 39 MO patients. The mean weight loss was 31.3 (range, 21-67 kg) and mean % excess BMI loss reached 72% (range, 64-97%). Neither leak nor disruptions of the staple line and/or sleeve dilatation were recorded. CONCLUSION: LSG is an effective and safe bariatric procedure with low incidence of complications and mortality in our experience.
- MeSH
- Surgical Stapling methods MeSH
- Adult MeSH
- Gastrectomy MeSH
- Weight Loss MeSH
- Body Mass Index MeSH
- Cohort Studies MeSH
- Laparoscopy MeSH
- Middle Aged MeSH
- Humans MeSH
- Obesity, Morbid surgery MeSH
- Retrospective Studies MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Female MeSH
INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is a bariatric procedure with very good long-term weight-reducing and metabolic effects. AIM: Here we report 6 years' experience with LSG performed in morbidly obese patients by one surgical team focusing on the impact of the degree of sleeve restriction and safety of the procedure without over-sewing the staple line. MATERIAL AND METHODS: From 2006 to 2012, 207 morbid obese patients with average age of 43.4 years and average body mass index 44.9 kg/m(2) underwent LSG without over-sewing the staple line. The complete 5- and 3-year follow-up is recorded in 59 and 117 patients with prospective data collection at 3, 6, 9, 12, 18, 24, 36, 42 and 60 months after LSG. Group 1 patients operated in 2006-2008 had smaller sleeve restriction. Group 2 patients operated in 2009-2012 had major sleeve restriction. All procedures were performed without over-sewing of the staple line. RESULTS: The average %EBMIL (excess body mass index loss) in group 1 patients with minor sleeve restriction reached 54.1% and average %EWL (excess weight loss) was 50.8% while in group 2 with major sleeve restriction the average %EBMIL reached 69.7% and average %EWL was 66.8%. Final weight reduction was significantly higher in group 2 patients compared to group 1 patients with smaller sleeve restriction. Out of 49 patients with preoperatively diagnosed T2DM (type 2 diabetes mellitus) was completely resolved in 70.8%. Pre-operatively diagnosed hypertension normalized in 64.2%, improved in 23.2%, and remained unchanged in 12.6% of patients. CONCLUSIONS: Carefully performed LSG without over-sewing the staple line is feasible and safe. A better weight-reducing effect was present in patients with major sleeve restriction.
- Publication type
- Journal Article MeSH
INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is one of the most efficient bariatric interventions in morbidly obese patients. The most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. AIM: To share our experience in managing the staple line leak after LSG and to help to find the best procedure that should be preferred. MATERIAL AND METHODS: In the 2010-2015 period we performed 223 LSG, with about 5 demonstrating severe complications - two patients with severe bleeding requiring revision surgery, and three patients with resection surface leak. RESULTS: We always primarily treated the staple line leak with a laparoscopic revision. Once the fistula did not spontaneously close after this treatment. A series of other methods were then indicated for this patient and only the sixth one resulted in the desirable therapeutic success. At first, our team opted for laparoscopic revision with drainage. The next procedure involved applying Ovesco and Boston clips. As a third method we performed abscess drainage through a nasobiliary tube inserted via gastroscopy. Due to failure we performed the second laparoscopic revision with staple line resuture, the next intervention was an open revision with fistula excision and suture, and finally we opted for the application of a self-expanding metallic stent, which proved to be definitely curative. CONCLUSIONS: Without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after LSG. It depends mainly on the clinician's experience and is lengthy and often untraditional.
- Publication type
- Journal Article MeSH
Článek poskytuje chirurgický pohled na řešení komplikací celosvětově hojně užívaného operačního výkonu, jakým je laparoskopická sleeve gastrektomie. Sleeve gastrektomie je celosvětově uznávaný bariatrický výkon. Tato operace je hodnocena jako bezpečná, nicméně i ona může být, i když v relativně malém procentu, provázena závažnými komplikacemi. Jednou z nejnebezpečnějších je staple line leak s rozvojem lokální, difúzní peritonitidy či torpidní píštěle. Řešení je svízelné a často je postupně realizováno několik způsobů ošetření, než dojde k definitivnímu zhojení pacienta. Léčbu této komplikace je možno rozdělit na čistě chirurgickou, kombinovanou či čistě endoskopickou. Neexistují nicméně dosud guidelines, jakým způsobem při této komplikaci postupovat, a je tedy terapeutický postup zvolen na základě klinických zkušeností pracoviště doplněných informacemi z dostupné literatury.
The article proposes a surgical look at solving the complications of the widely used surgical procedure worldwide, such as laparoscopic sleeve gastrectomy. Laparoscopic sleeve gastrectomy (LSG) is considered as one of the most efficient bariatric interventions in morbid obesity wordwide. Nevertheless, there are some risks and perhaps the most severe is leak along the staple line with local or diffuse peritonitis or persisting fistula. The treatment of this complication can be strictly surgical, combined or only endoscopic. However, there are no set guidelines to date as the best option of leak management. As a result, every procedure is "tailored" to a specific patient and it always depends on the experience of the respective institutionsupplemented with information available from literature.
OBJECTIVE: To demonstrate the use of a single-stapler technique during rectosigmoid resection in women with deep infiltrating endometriosis (DIE). DESIGN: A step-by-step video demonstration of rectosigmoid resection and end-to-end anastomosis using two circularly placed sutures and one circular stapler. SETTING: Institute for the Care of Mother and Child, Prague, Czech Republic. PATIENT(S): A 39-year-old woman presented with primary sterility and deep infiltrating endometriosis, and an EZIAN score of A2,B2,C3. A nodule was located 9 cm from the anus and was 38 × 9 mm in size. This included an intramural fibroma of 6 cm and a left-sided ovarian endometriotic cyst of 6 cm. Her pain on the visual analogue scale were dysmenorea 6, dyspareunia 5-6, dyschezie 7, dysuria 0, and acyclic pain 5. INTERVENTIONS: The primary objective was to replace the linear-stapler resection with two simple, strictly circularly placed sutures, to cut the intestinal wall between them, and to form the end-to-end anastomosis with a circular stapler. The one-stapler technique consisted of the following steps: intestinal wall cleansing as in the limited segmental resection; placement of one strictly circular suture just below the DIE nodule, without fixation; placement of the first circular suture just below the DIE nodule, ideally with at least three full-thickness "bites" of the intestinal wall; placement of the second circular stitch approximately 2 cm below the first one in a similar manner (three full-thickness "bites"); interruption of the intestinal wall with a harmonic scalpel; end-to-end intestinal anastomosis with a circular stapler; and airtightness test of the anastomosis. This results in only one incision line and therefore a lower risk of leakage. Intestinal resection time was on average 10 minutes longer compared to that for the linear stapler technique. So far, we have successfully performed the procedure in 25 women. Perioperative leakage was observed in two of these 25 patients in the classical procedure group and in none of the 25 patients in the group with the one-stapler technique. There were no differences in C-reactive protein (CRP) on third and fifth postoperative days or in other complications such as bleeding and pyrexia). The cost of procedure is lowered by the decrease in the number of staplers from 3 to 1. The patients' postoperative follow-up was uneventful, and they were discharged from the hospital at the same time as the women in whom the classical stapler technique was performed. MAIN OUTCOME MEASURES(S): The primary outcome was the development of a new surgical approach to resection rectosigmoid endometriotic nodules that would decrease the number of incision lines on the intestine. The secondary outcome measures were peri- and postoperative complications (i.e., bleeding, intestinal leakage, postoperative infection, CRP), length of the surgery and hospitalization, and cost of the procedure. CONCLUSION: Multiple incision lines following resection of the rectosigmoid colon and end-to-end anastomosis are risk factors for postoperative intestinal leakage. Therefore, a single incision line formed with two circular sutures, and one circular stapler may reduce the risk of postoperative complications and also financial expenses of the procedure. We believe that this method is suitable and easiest for nodules located less than 6 cm from the anal verge because of possible complications with angulation of linear stapler.
- MeSH
- Colon, Sigmoid diagnostic imaging surgery MeSH
- Adult MeSH
- Endometriosis diagnostic imaging surgery MeSH
- Laparoscopy methods MeSH
- Humans MeSH
- Rectum diagnostic imaging surgery MeSH
- Suture Techniques * MeSH
- Sutures * MeSH
- Video-Assisted Surgery methods MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Female MeSH
- Publication type
- Video-Audio Media MeSH
- Journal Article MeSH
- Case Reports MeSH
Cíl: Hodnocení výskytu chirurgických komplikací nově zaváděné operační metody - staplerové hemoroidektomie podle Longa a možnosti jejich řešení. Metodika: Prospektivní klinické sledování skupiny nemocných, u kterých byla během období 2 let (1. 12. 2000-30. 11. 2002) provedena staplerová hemoroidektomie podle Longa. Sledování bylo zaměřeno na chirurgické komplikace metody. Klinické kontroly po propuštění probíhaly v intervalu 3 týdnů a 3 měsíců od operace. V případě obtíží nemocného při poslední kontrole pokračují sledování i léčba déle. Výsledky: Staplerová hemoroidektomie byla během 2 let provedena celkem u 52 nemocných (100,0 %). U 11 operovaných (21,2 %) se vyskytly chirurgické komplikace. Nejvážnější komplikací bylo masivní pooperační krvácení, které se objevilo u 4 pacientů (7,6 %). Z ostatních komplikací jsme pozorovali rozvoj stenózy anu. perianální infekci, akutní anální fisuru a močovou retenci. Závěr: Longova metoda se dnes řadí mezi možné varianty operační léčby hemoroidů. Z vážných chirurgických komplikací jsme pozorovali krvácení z oblasti staplerové sutúry a vznik stenózy anu. Cílem sdělení je upozornit na chirurgické komplikace metody, možnosti jejich léčby a prevence.
Background: The aim of this article is an assessment of new surgical procedure - stapled hemoroidectomy according to Longo. We do concentrate on surgical complications and possibilities of it's management. Methods: Prospective, clinical follow up of patients in which stapled hemorrhoidectomy was performed during the period of 2 years (1st December 2000 - 30st November 2002). Observation concentrates on surgical complications of this method. All patients had a clinical check up 3 weeks and 3 months after surgery. In case of any problems treatment and follow up continues. Results: Stapled hemoroidectomy was performed during the period of 2 years in 52 patients (100%). There was 11 patients (21.2%) with some of surgical complication. The most serious one was massive rectal bleeding after surgery, which has been observed in 4 patients (7.6%). Other surgical complications observed in our group were anal stenosis, local infection, acute anal fissure and retention of urine. Conclusion: Stapled hemoroidectomy is now one of feasible alternatives for surgical treatment of hemoroids. Serious surgical complications observed in our patients were bleeding from the stapled suture line and anal stenosis. The aim of this article is to refer possible surgical complications of this method, it's prevention and management.
- MeSH
- Surgical Stapling methods MeSH
- Surgical Staplers MeSH
- Hemorrhoids diagnosis surgery MeSH
- Humans MeSH
- Postoperative Complications etiology prevention & control therapy MeSH
- Postoperative Hemorrhage etiology prevention & control therapy MeSH
- Prospective Studies MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
- Comparative Study MeSH
Úvod: Laparoskopická sleeve gastrektomie (LSG) patří mezi nejčastěji prováděné bariatrické výkony. Rovněž je ale spojena se závažnými a potenciálně život ohrožujícími komplikacemi souvisejícími se staplerovou linii, jako je „leak“ ze žaludku a krvácení. Kazuistika: Popisujeme případ operačního řešení časné píštěle mezi žaludkem a slezinou 3 týdny po LSG. Svou pozornost jsme zaměřili na diagnostiku a možnosti léčby této závažné komplikace. Závěr: Snaha o snížení četnosti výskytu leaku po LSG zahrnuje celou řadu nejrůznějších opatření. Je vhodné mít odborné znalosti nejen v primární bariatrické operativě, ale také v řešení problémů a reoperací v gastrointestinální chirurgii. Základním předpokladem úspěšné terapie je individualizace přístupu a multidisciplinární týmová spolupráce.
Introduction: Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric procedures. But it is also associated with serious and potentially life-threatening staple line-related complications, such as stomach leak and bleeding. Case report: The article describes a case of surgical treatment of an early fistula between the stomach and the spleen 3 weeks after LSG. We have focused our attention on the diagnosis and possible treatment options for this potentially life-threatening complication. Conclusion: Efforts to reduce the frequency of leakage after LSG include a number of different measures. It is advisable to have expert knowledge not only in primary bariatric surgery, but also in the management of problems and reoperations in gastrointestinal surgery. An individualized approach and multidisciplinary teamwork are essential for successful therapy.
- MeSH
- Bariatric Surgery MeSH
- Gastrectomy * methods adverse effects MeSH
- Laparoscopy methods adverse effects MeSH
- Humans MeSH
- Obesity, Morbid surgery MeSH
- Anastomotic Leak MeSH
- Fistula surgery MeSH
- Postoperative Complications surgery diagnosis etiology MeSH
- Retrospective Studies MeSH
- Check Tag
- Humans MeSH
Úvod: Narůstající důležitost jaterní resekce v léčení benigních a maligních hepatobiliárních onemocnění je dána i významným snížením operační mortality a pooperační morbidity v posledních letech jako výsledek zlepšení ve výběru nemocných, v chirurgické technice a v perioperační péči. Cílem sdělení bylo vyhodnocení kombinace novějších technik u jaterní transekce na základě vlastních zkušenosti a výsledků z recentních studií. Materiál, metoda a výsledky: V období od roku 1999 do května 2005 byla provedena na chirurgické klinice Fakultní nemocnice Královské Vinohrady v Praze resekce jater u 133 nemocných s benigním nebo primárním a sekundárním maligním nádorem. K transekci jater byl postupně použit od roku 1999 harmonický skalpel, utrazvukový disektor, vodní tryskový skalpel, bipolární diatermie, argonová koagulace a radiofrekvence. Disekce jaterní tkáně pomocí ultrazvukového disektoru nebo vodního tryskového skalpelu v kombinaci s harmonickým skalpelem nebo bipolární diatermickou koagulací snížila peroperační ztrátu krve u rozsáhlejších neanatomických resekcí jater. Tato metoda disekce byla použita i u některých „ centrálně“ lokalizovaných nádorů k neanatomické resekci. Benefit použité kombinace metod je dán dostatečnou koagulací a přerušením menších větví cév a žlučovodů v resekční linii bez zajištění intermitentního uzávěru přítoku krve do jater Pringleho manévrem. Radiofrekvence jako nová metoda ablace nádorů jater byla použita u anatomické i neanatomické resekce jater k předtransekční koagulaci jaterní tkáně k zajištění R0 resekce. Pooperační morbidita se vyskytla ve 14 % (19 nemocných). Do 30 dnů po operaci nebylo zaznamenáno úmrtí. Závěr: 1. Použité techniky transekce jater pomocí ultrazvukového disektoru nebo vodního tryskového skalpelu jsou bezpečné metody resekce jater představující alternativy snižující krevní ztrátu. 2. K uzávěru s přerušením menších intraparenchymových větví cév a žlučovodů je alternativou harmonického skalpelu použití diatermické koagulace. 3. Kombinace techniky ultrazvukového disektoru nebo vodního tryskového skalpelu s harmonickým skalpelem nebo diatermickou koagulací zajišťuje resekci jater uzávěrem a přerušením cév a žlučovodů v resekční linii. 4. Použití radiofrekvence k pretransekční koagulaci jaterního parenchymu vede ke zmenšení krvácení při resekci a je metodou volby resekce centrálně lokalizovaných nádorů s omezením ztráty funkčního parenchymu.
Introduction: The liver resection procedure as a treatment method of benign and malignant hepatobiliary disorders grows more important due to the fact, that its postoperative morbidity and mortality rates have been reduced, a result of the patients selection method, surgical techniques and perioperative care improvements. The aim of this report was to assess combinations of recent liver transsection techniques, based on the authors‘ own experience and results of recent studies. Material, Methods and Results: From 1999 to May 2005, in the Surgical Clinic of the Faculty Hospital Královské Vinohrady in Prague, the liver resection procedure was completed in 133 patients with benign or primary and secondary malignant tumors. In the liver transsection procedure, the following instrumentation was used, starting from 1999: harmonic scalpels, ultrasonographic dissectors, water jet scalpel, bipolar diathermia, argon coagulation and radiofrequency. The liver tissue dissection using the ultrasonographic dissector or the water jet scalpel in combination with the harmonic scalpel or bipolar diathemic coagulation, reduced the postoperative blood loss in extensive non-anatomical liver resections. This dissection method was also used in some “centrally“ located tumors for their non-anatomical resections. The benefit of the combination of the methods is based on sufficient coagulation and interruption of minor vascular branches and bile ducts in the resection line, without intermittent closure of the blood influx to the liver, using a Pringle manoeuvre. The radiofrequency, as a novel method for the liver tumors ablation, was used in anatomical and non-anatomical liver resections to coagulate the liver tissue prior to its transection prior to the R0 resection. The postoperative morbidity rate was 14% (19 patients). Within 30 postoperative days, no death was recorded. Conclusion: 1. The above listed liver transsection techniques, employing the ultrasonographic dissector or water jet scalpel, are safe alternative liver resection methods, reducing the blood loss. 2. Diathermic coagulation is an alternative to the harmonic scalpel for intersecting minor intraparenchymatous vascular branches and bile ducts. 3. A combination of the ultrasonographic dissector technique or water jet scalpel with the harmonic scalpel or diathermic coagulation technique, aids the liver resection by closing and interrupting the vessels and bile ducts in the resection line. 4. Radiofrequency and pre-transsectional coagulation of the liver parenchyma reduces the bleeding during the resection procedure and is a method of choice in resections of centrally located tumors, reducing the loss of the functional parenchyma.
