Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy.

BACKGROUND: The most common postoperative complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leak. Even if its rate following LSG has been recently reduced, management of chronic leaks remains challenging. OBJECTIVE: To present a series of patients treated with laparoscopic Roux-en-Y fistulojejunostomy (LRYFJ) for chronic gastric leak (>12 wk) post-LSG. SETTING: University hospitals; specialized bariatric surgery units. METHODS: Data were prospectively gathered and retrospectively analyzed. Parameters of interest were patient characteristics, perioperative data, and postoperative outcomes. Hemodynamically unstable patients and/or presentations of signs of severe sepsis were excluded. Surgical technique was standardized. RESULTS: Fourteen patients underwent LRYFJ for chronic gastric leak (12 women, 2 men). The mean age was 49.2 years and the mean weight was 88.7 kg with a mean body mass index of 31.1 kg/m2. All procedures were successfully performed by laparoscopy except 1 (7.1%) converted to open surgery. The mean operative time was 198 minutes, with a mean estimated blood loss of 135.7 mL and 2 patients necessitating transfusion (14.2%). Mortality was null. Five postoperative complications were noted (35.7%): 2 leaks of the fistulojejunostomy treated by antibiotherapy and endoscopic drainage; 1 perianastomotic hematoma treated by relaparoscopy and antibiotherapy; and 1 pleural effusion and 1 hematemesis both medically treated. The mean length of hospital stay was 14 days. The mean follow-up was 40 months, with all patients being in good health at last contact. CONCLUSIONS: LRYFJ seems to be a good salvage option in selected patients for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons.

Mesenchymal Stem Cells and Platelet Rich Plasma Therapy to Treat Leak After Sleeve Gastrectomy.

BACKGROUND: One of the most feared and life-threatening complications after sleeve gastrectomy (SG) is staple line leak, with an incidence between 1 and 4%. Stable patients may be managed conservatively, with antibiotics, percutaneous drainage and endoscopy-based treatment. We propose mesenchymal stem cells (MSC) and platelet rich plasma (PRP) therapy as an innovative technique to treat leak after SG. MATERIAL AND METHODS: Bone marrow MSCs is obtained by centrifugation of tibial puncture specimen. A peripheral whole blood sample is retrieved from the patient and centrifuged to obtain PRP. During endoscopy, the first 10 mL are injected in 4quadrants (equal volume) in the submucosae around the internal orifice. The second 10 mL are injected in the wall of the fistula tract. RESULTS: The immediate course following the endoscopy was uneventful in both reported cases. The leaks healed in 30 and 42 D, respectively. Oral nutrition was progressively started during the third WK and fourth WK following the injection for both patients. No adverse event was noted during the follow-up period. CONCLUSION: The management of fistulas post SG is controversial and actual available treatments present a relatively prolonged healing time. MSC administration retains a high potential value in the treatment of these fistulas. Further studies and wider clinical trials are mandatory to determine the impact of MSC administration.