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Case report LSG: Benefits of intraoperative endoscopy
Researchers from the Presence Saint Joseph Hospital and Chicago Institute of Advanced Bariatrics, Chicago, IL, US, have hailed the benefits of laparoscopic sleeve gastrectomy (LSG) intra-operative endoscopy for leak testing. The paper, ‘Benefits of intraoperative endoscopy: case report and review of 300 sleeves gastrectomies’, published in the Annals of Surgical Innovation and Research, outlines a case demonstrating the benefits of endoscopy intra-operatively, as well as discussing their experience of 200 consecutive sleeve gastrectomies.
“We believe that taking the extra time to perform a leak test using an endoscope will pay dividends for both the practitioner and the patient.”
They present the case of a 37 year old female with a past medical history significant for morbid obesity, gastroesophageal reflux disease, and asthma. She had significant surgical history for a previous tubal ligation and laparoscopic cholecystectomy. Her preoperative BMI was 47.6.
The patient was taken into operating room and the procedure began with a 5mm incision in the left upper midclavicular line and inserted a trochar under direct vision with a 5mm 0° camera. They placed four working ports total, as well as a Nathanson liver retractor. The sleeve technique involved freeing the greater curvature starting 5cm proximal to the pylorus, with complete dissection to the left crus to avoid leaving any retained fundus behind. The patient also had a small 1cm hiatal hernia which was dissected and then closed with an anterior figure of eight stitch.
The sleeve was constructed over a 34F Ewald tube with a reinforced staple line (Seamguard, WL Gore), though the authors state that they often use a blunt tip bougie. They paid special attention to avoid tightness at the incisura and angle of His. After creation of the sleeve, the patient had routine post-operative endoscopy, in which a blood clot was noticed in the lower oesophagus, an unusual finding. Once in the stomach, the staple line was found to be straight and there was no bubbling on the leak test and no blood was identified in the stomach or staple line. The patient was then extubated after the specimen was removed and brought to the post-anaesthesia care unit (PACU).
In the PACU, about 15 min after extubation, the patient started to develop hematemesis, about 10 cc every 2–3 min of fresh blood. They re-intubated the patient to bring her back into the operating room for an endoscopy. They located a small tear in the lower oesophagus that was bleeding (Figure 1). This area was injected with 7ml of 1:10,000 epinephrine, which prevented further bleeding, and the staple line remained intact.
“The abdominal cavity was not entered in the operating room as we felt that there were no areas of concern in the stomach during our initial endoscopy and this remained the case upon second inspection,” the authors note.
Under direct vision, an orogastric tube was placed and the patient was kept intubated for six hours post-operatively and then extubated without difficulty. The patient remained hemodynamically stable with stable haemoglobins of 11.0–13.0 g/dl. They routinely perform an upper GI on post-operative day one to assess for leak or obstruction (Figure 2). Her postoperative visits have revealed no long term sequelae. At six months, she has had 53% excess weight loss with no dysphagia or reflux symptoms.
The authors state that by utilising intraoperative endoscopy as their primary seal verification and to inspect the newly created staple line for bleeding or twists. Data from their experience shows that they have had one leak in over 300 cases.
The authors state that there are multiple benefits to performing intraoperative endoscopy:
- The ability to check for internal bleeding within the staple line also gives additional assurance and information to the surgeon.
- The bougies that are placed are not benign instruments, and can cause damage to either the stomach or oesophagus upon insertion.
- Checking the lumen after sleeve creation allows for early identification of potential injury.
- For revisional bariatric surgery, pre-operative endoscopy is essential to evaluate causes of failure of the initial procedure.
- Benefits to technical skills and education of the surgeon/endoscopist - as endoscopic treatments for operative complications are becoming more prevalent, the surgeon must be aware of the appearance of normal sleeve construction. This provides residents with an opportunity to enhance their skills and increase their endoscopy cases.
“Overall, our experience has been very positive with utilization of intraoperative endoscopy after creation of our sleeve gastrectomy,” the authors conclude. “Our leak rate is extremely low and occurred very early in our experience, and we believe that taking the extra time to perform a leak test using an endoscope will pay dividends for both the practitioner and the patient.”
To access this paper, please click here