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BACKGROUND@#Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting.@*METHODS@#To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks.@*RESULTS@#A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor.@*CONCLUSIONS@#Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.
Subject(s)
Humans , Male , Retrospective Studies , Diabetes Mellitus, Type 2/complications , Obesity, Morbid , Anastomotic Leak/epidemiology , Gastrectomy/methods , Reoperation/methods , Registries , Laparoscopy/methods , Treatment OutcomeABSTRACT
Objective:To investigate the clinical efficacy of laparoscopic sleeve gastrectomy in obese adolescents.Methods:The retrospective and descriptive study was conducted. The clinical data of 37 obese adolescents who were admitted to Drum Tower Hospital Affiliated to Nanjing University Medical School between July 2016 and August 2020 were collected. There were 18 males and 19 females, aged 18(range, 13?19)years. All patients underwent laparoscopic sleeve gastrec-tomy. Observation indicators: (1) surgical and postoperative situations; (2) follow-up. The patients were followed up by outpatient review to detect body weight, blood glucose, blood lipid, blood pressure, nutrition situation and related complications at 3, 6 and 12 months after operation. The follow-up was up to August 2021. Measurement data with normal distribution were represented as Mean± SD. Repeated measurement data were analyzed by Repeated Measures Anova. Measurement data with skewed distribution were represented by M(range). Count data were expressed as absolute numbers or percentages. Results:(1) Surgical and postoperative situations. All 37 patients under-went laparoscopic sleeve gastrectomy successfully, the operative time was (50±7)minutes, the volume of intraoperative blood loss was (53±17)mL, and the duration of postoperative hospital stay was (3.0±0.5)days. Of the 37 patients, 2 cases had puncture infection. There was no complication such as bleeding occurred. (2) Follow-up. Of the 37 patients, 35, 31 and 22 cases were followed up at postoperative 3, 6 and 12 months, respectively. There was no anemia, malnutrition, trace element deficiency or other nutrition-related complications during the follow-up, and there was no death. The body mass, body mass index, homeostasis model assessment-insulin resistance, triglyceride, total cholesterol, systolic pressure, diastolic pressure, vitamin D, folate of the 37 patients were (117±19)kg, (40±5)kg/m 2, 6.59(range, 2.84?28.02), (1.6±0.7)mmol/L, (4.5±0.7)mmol/L, (141±22)mmHg (1 mmHg=0.133 kpa), (84±18)mmHg,(14±5)μg/L, (10±5)μg/L before the surgery, and (81±15)kg, (27±4)kg/m 2, 2.69(range, 1.08?9.71), (0.9±0.5)mmol/L, (4.5±0.7)mmol/L, (115±15)mmHg, (70±11)mmHg, (23±10)μg/L, (9±5)μg/L at postoperative 12 months. There were significant differences in the time effect of above indicators ( Ftime=214.14, 160.37, 12.66, 11.77, 2.90, 18.08, 11.32, 8.61, 5.04, P<0.05). The percentages of excess of body mass index lost of the 37 patients were 48%±19%, 77%±28% and 89%±24% at postoperative 3, 6 and 12 months, the percentages of excess weight loss were 42%±13%, 63%±17% and 75%±18%, the percentages of total body weight loss were 18%±5%, 26%±6% and 34%±7%, respectively. There were significant differences in the time effect of above indicators ( Ftime=83.96, 107.24, 109.06, P<0.05). The hemoglobin A1c was 4.8%, 5.0%, 5.1% and 4.9%, 5.2%, 5.2% in the 2 patients with type 2 diabetes at postoperative 3, 6 and 12 months, respectively, and they were relieved without drug treatment. Conclusion:Laparoscopic sleeve gastrectomy has definite short-term clinical efficacy in the treatment of adolescent obesity, which can effectively reduce excess body weight and improve the metabolic complications of insulin resis-tance, dyslipidemia and hypertension.
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Objective:To investigate the application value of Laennec approach in laparoscopic anatomical right hemihepatectomy (LARH).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 2 female patients who underwent LARH via Laennec approach in the First Affiliated Hospital of Kangda College of Nanjing Medical University from May to July 2020 were collected. The two patients were 51 and 57 years old, respectively. Observation indicators: (1) surgical situations; (2) postoperative situations and follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect post-operative survival and tumor recurrence of patients up to December 2020. Count data were repre-sented as absolute numbers.Results:(1) Surgical situations: 2 patients successfully underwent LARH via Laennec approach, without conversion to open surgery. The operation time was 180 minutes and 185 minutes, and the volume of intraoperative blood loss was 200 mL and 400 mL, respectively. No blood transfusion or gastrointestinal decompression was performed in either patient. (2) Postoperative situations and follow-up: 2 patients began to take liquid diet on the first day and out-of-bed activities on the postoperative second to third day. There was no postoperative bile fistula or bleeding, but different degrees of peritoneal and pleural effusion occurred to the 2 patients after operation. One case was improved after right-sided thoracentesis and chest tube drainage due to dyspnea, and the other case was cured after conservative therapy. There was no perioperative death. The duration of postoperative hospital stay of 2 patients was 13 days and 11 days, respectively. Results of pathological examination showed 1 case of hepatic hemangioma and 1 case of primary liver cancer, respectively. The Laennec capsule was observed on the hepatic vein branches of segment Ⅴ, Ⅵ, Ⅶ, Ⅷ, and the gap existed between the Laennec capsule and the hepatic vein. Two patients were followed up for 7 months and 5 months，respectively. They survived during the follow-up，without tumor recurrence.Conclusion:It is safe and feasible to perform LARH by Laennec approach.
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The iatrogenic cause of bile duct stone formation is mainly due to suture materials, especially silk sutures. In recent years, Prolene and Vicryl sutures have been widely used in biliary surgery, and bile duct stone formation related to sutures are seemingly becoming rare, as there has only been one report of bile duct stone formation caused by Prolene sutures in the literature. In the last few years we have had two cases of Prolene suture-related bile duct stone formation within our unit. We therefore suggest that Vicryl sutures should be used as the first choice in biliary surgery, in order to prevent the formation of iatrogenic bile duct stones
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Objective To explore the therapeutic strategy and clinical value of intraoperative chole-dochoscopy and electrohydraulic lithotripsy for refractory intrahepatic bile duct stones.Methods Liver pa-renchyma,intrahepatic bile duct and bile duct stones were explored under direct vision and intraoperative choledochoscope in 1 1 cases of refractory intrahepatic bile duct stones.Electrohydraulic lithotripsy and lithot-omy were performed to remove the stones and protect the liver parenchyma.If the stones could not be re-moved once,a secondary lithotripsy and lithotomy was performed through the fistula tract.Results All re-fractory calculi were crushed after one or two procedures and the clearance rate were 100%.No complica-tions occurred.Ten patients were followed up from 1 to 3 years except one.Three cases revealed recurrent stone during follow-up due to withdrawal of ursodeoxycholic acid capsules in 1 to 2 years.Seven others showed no stone recurrence within follow-up time.Conclusion Intraoperative choledochoscopy and electro-hydraulic lithotripsy is an easy technique and can effectively protect the liver parenchyma.The life quality of patients can be improved with low surgical risk and postoperative complications.
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Objective To evaluate the clinical diagnosis of gastric stromal tumors and the safety and feasibility with laparoscopic wedge resection.Methods The clinical data of diagnosis and treatment were retrospectively analyzed in 43 cases diagnosed as gastric stromal tumors by endoscopyic ultrasonography.Results Thirty-six cases were successful by laparoscopic surgery success rate being 83.7%.Endoscopic ultrasonography diagnosis rate was 69.0%.The positive rate of CD117 and CD34 in postoperative diagnosis of gastrointestinal stromal tumor wasl00%.The mean post-operative hospital stay was 5 days.Conclusion Endoscopyic ultrasonography can be selected as a main method for clinical diagnosis of gastric stromal tumors and laparoscopic resection was safe and feasible.
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Objective: To observe the role of parenteral nutrition and laparoscopic therapy in chylous ascites.Methods: A patient with chylous ascites was therapied with parenteral nutrition(4 weeks) and laparoscopic therapy and parenteral nutrition(1 week) subsequently.Output of ascites was daily measured from the drainage catheter of abdominal cavity.The body weight and other nutritional indexes were determined.Results: During the course of parenteral nutrition,the production and output of ascites gradually decreased,the body weight increased,and the serum album in level kept unchanged.After laparoscopic therapy and parenteral nutrition(1 week),ascites decreased significantly and did not rebound after diet,the body weight and the serum album in level also obviously increased.Conclusion: Laparoscopic therapy and parenteral nutrition are very useful in the treatment of patients with chylous ascites.