Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass

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1 OBES SURG (2008) 18: DOI /s RESEARCH ARTICLE Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass Carlos Ballesta & René Berindoague & Marta Cabrera & Miquel Palau & Magdiel Gonzales Received: 23 July 2007 /Accepted: 19 August 2007 / Published online: 8 April 2008 # Springer Science + Business Media B.V Abstract Background Anastomotic leaks after bariatric surgery carry high morbidity and mortality. We aimed to describe our experience of the diagnosis and management of gastrointestinal anastomotic leaks in patients undergoing laparoscopic gastric bypass in a single institution. Methods Of 1,200 patients who underwent laparoscopic Roux-en-Y gastric bypass with manual gastrojejunal anastomosis for morbid obesity from January 2002 to January 2007, we retrospectively analyzed 59 patients with anastomotic leak. The location of the leak, day of diagnosis, diagnostic methods, clinical manifestations, treatment modalities, associated complications, and length of hospital stay were analyzed. Results Leaks were located as follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8% in undetermined sites. Routine upper gastrointestinal series revealed contrast extravasation in nine patients (15.3%). Leaks were asymptomatic at diagnosis in 29 patients (49.2%). Surgical reintervention was carried out in 23 patients, and conservative treatment was provided in the remaining 36. Transfer to the intensive care unit was required in 11 patients, with five deaths (0.4%). C. Ballesta : R. Berindoague : M. Cabrera : M. Palau : M. Gonzales Centro Laparoscópico de Barcelona, Centro Médico Teknon, Barcelona, Spain R. Berindoague (*) Calle Vilana, 12 Despacho 174, Barcelona, Spain berindoague@clb.es Conclusion In our experience, most anastomotic leaks can be managed with conservative measures alone. In many patients, abdominal drains are effective in the management of leaks, obviating the need for reintervention. Nasoenteral nutrition was effective in the non-operative management of gastrojejunal leaks in patients without signs of systemic toxicity. Keywords Morbid obesity. Gastric bypass. Laparoscopy. Complications. Anastomotic leak. Laparoscopic Roux-en-Y gastric bypass. Bariatric surgery Introduction Although surgery offers the only effective long-term weight loss therapy for the morbidly obese, operative complications in these patients can be severe and life threatening. Anastomotic leaks are the most dreaded and potentially devastating complication of this type of surgery and carry high morbidity and mortality. The incidence of this complication after Roux-en-Y gastric bypass (RYGBP) ranges from 0 to 5.2% in large series and does not differ in laparoscopic or open RYGBPP [1 3]. Anastomotic leak remains the second leading cause of death after RYGBP surgery. Consequently, efforts to improve the prevention, diagnosis, and treatment of anastomotic leaks after bariatric surgery are paramount. The management of this complication is usually operative, which carries high mortality. Non-operative treatment may be a valid alternative in these patients, but little has been published on this approach. Furthermore, the management of anastomotic leaks varies according to the time of diagnosis.

2 624 OBES SURG (2008) 18: The aim of this study was to establish the incidence of anastomotic leak in our center, review and document the spectrum of clinical presentations, the use and effectiveness of diagnostic tests, and treatment outcomes in patients who developed anastomotic leaks after laparoscopic RYGBP for morbid obesity. To do this, we reviewed our prospective database of 1,200 laparoscopic RYGBP procedures to define risk factors related to intestinal leak. Materials and Methods Of 1,200 patients who underwent laparoscopic RYGBP with totally hand-sewn gastrojejunal anastomosis (GJA) for the treatment of morbid obesity in a single institution from January 2002 to January 2007, postoperative leak occurred in 59 (4.9%). Postoperative leak was defined as anastomotic disruptions, either at the gastrojejunostomy or the jejunojejunostomy, or staple line disruptions. The selection criteria for bariatric surgery included body mass index (BMI)>40 kg/m 2 or between 35 and 40 kg/m 2 with associated comorbidities, according to the National Institute of Health Consensus Development Panel, and previous failed bariatric procedures (lack of effectiveness or excessive weight loss due to persistent vomiting). Our initial technique has previously been described [4]. Recently, we increased the gastric pouch volume from 30 to 50 ml. A five-port technique was used to perform the entire procedure. A vertical gastric pouch was created first by horizontal transection of the stomach using a 45-mm linear cutter and a 3.5-mm stapler (EndoGIA, US Surgical Corp, Norwalk, CT, USA) followed by vertical ascending transection toward the Hiss angle using a 60-mm linear cutter and a 3.5-mm stapler, which was fired twice. Next, the proximal jejunum was divided with a 45-mm linear cutter and a 2.5-mm stapler, cm distal to the ligament of Treitz and without division of its mesenterium. The alimentary limb was 250 cm long in patients with a BMI<50 kg/m 2, 300 cm in patients with a BMI between 50 and 60 kg/m 2, and 350 cm in those with a BMI>60 kg/m 2. A side-to-side jejunojejunostomy was performed using a 30-mm linear cutter and a 2.5-mm stapler. The enterotomy was closed using interrupted 2 0 polyglactin sutures. The Roux-en-Y limb was brought up to the gastric reservoir in an antecolic antegastric position. The GJA was constructed using 2 0 polyglactin sutures in a totally hand-sewn fashion. This was accomplished in two layers (one interrupted suture followed by another continuous suture) for the posterior side of the anastomosis and in one layer for the anterior side (interrupted suture) of the GJA. Patency and water tightness at the GJA and gastric pouch section line were routinely checked by injection of methylene blue dye. A multitubular drain (Mentor Porgés S.A.S, France) was routinely placed posterior to the GJA and along the gastric section line, between the gastric pouch and the gastric remnant, and was exteriorized through the right hypochondrium. Another tubular drain with a 4.7-mm diameter (Redon Drain Ch-14) was positioned behind the spleen and exteriorized through the left hypochondrium. A cholecystectomy was simultaneously performed in patients with sludge or gallstones detected on preoperative ultrasonography. Postoperative care was standardized in all patients and included subcutaneous low molecular weight heparin for the first 2 weeks after surgery; upper gastrointestinal series (UGS) with water-soluble contrast (Gastrografin, Berlimed S.A, Madrid, Spain) swallow were performed in the first or second day after surgery. If the contrast passed through the bowel and there was no evidence of leak, gastric dilatation, or obstruction, the patient s diet was advanced. The patients were discharged on postoperative day 3 or 4. Proton pump inhibitors were administered for the first postoperative month. Tubular drainage was removed on postoperative day 3 and multitubular drainage on postoperative days 6 8. Statistical Analysis Data were collected retrospectively and outcome measures were analyzed and compared between groups. The primary outcome measure and dependent variable was anastomotic leak. Categorical variables were compared using Pearson s chi-square test and Fisher s exact test (SPSS 14.0 Chicago, IL). A P value of <0.05 was considered statistically significant. Quantitative variables were analyzed using the Mann Whitney non-parametric test. Results Of the 1,200 patients who underwent laparoscopic RYGBP with an antecolic antegastric position and totally handsewn GJA, 59 (4.9%) developed leaks during the postoperative period. Table 1 shows the clinical characteristics of all patients, with and without leaks, during the postoperative period. A history of previous abdominal procedures was present in 20 patients (33.9%). Conversion to laparoscopic RYGBP was performed in 11 patients (18.6%) who had undergone a previous bariatric procedure (vertical banded gastroplasty or laparoscopic gastric banding). In these patients, prior bariatric procedures were significantly associated with the development of leaks. Cholecystectomy simultaneously performed in a further 11 patients (18.6%) showed no statistically significant association with the development of leaks. The median operative time was 120 min.

3 OBES SURG (2008) 18: Table 1 Clinical characteristics and surgical results of 1,200 patients undergoing laparoscopic gastric bypass with and without leaks during the postoperative course Clinical characteristic and surgical results With leaks (n=59) n (%) Without leaks (n=1,141) n (%) P value Age (years) median (range) 43.0 (18 70) 38 (15 70) Age >55 years old 10 (16.9) 71 (6.2) Male gender 20 (33.9) 246 (21.6) BMI (kg/m 2 ) median (range) 44.6 ( ) 43.6 ( ) 0.08 BMI >50 kg/m 2 19 (32.2) 186 (16.3) Revisional surgery 11 (18.6) 52 (4.6) <0.001 Simultaneous cholecystectomy 11 (18.6) 126 (11.0) 0.09 Death 5 (8.5) 6 (0.5) <0.001 Operative time in minutes (median) In the group of patients with leaks, the median age was 43.0 years (range 18 to 70 years) and 20 (33.9%) were men. The median BMI was 44.6 kg/m 2 (range 35.5 to 80.2 kg/m 2 ). Ten patients (16.9%) were aged more than 55 years old, and 19 patients (32.2%) had a BMI>50 kg/m 2. Most of the patients who developed leaks had multiple comorbidities, including hypertension (45.8%), osteoarthritis (81.3%), gastroesophageal reflux disease (22.0%), obstructive sleep apnea (62.7%), venous insufficiency (61.0%), type 2 diabetes (23.7%), hyperlipidemia (47.8%), urinary stress incontinence (33.9%), and heart disease (30.5%). The location and day of diagnosis of postoperative leaks are shown in Fig. 1. Forty-one patients (69.5%) developed anastomotic leaks at the gastrojejunostomy, one of them with an associated leak at the gastric pouch. In four patients, the precise location was not determined. Diagnosis of leaks was made in less than 48 h after surgery in 17 patients (28.8%) and after 48 h in the remaining 42 (71.2%). Leaks were diagnosed during admission for RYGBP in 25 patients (42.4%) and during readmission in the remaining 34 patients (57.6%). The methods used to diagnose leaks consisted of clinical manifestations alone, UGS used either routinely or selectively to evaluate the GJA, computed tomography (CT) scan, or oral administration of methylene blue and observation of its effluence through the drains. In one patient, definitive diagnosis was based on clinical suspicion alone, without CT scan or UGS. In the remaining patients, clinical suspicion was confirmed by contrast studies, CT scan or drainage (positive methylene blue test; Table 2). Routine contrast study using water-soluble contrast (Gastrografin ) on postoperative day 1 or 2 was performed in 48 patients (81.3%; Table 3). Contrast extravasations in the UGS were observed in nine patients (15.3%). In a further 39 patients (66.1%), the results of UGS were normal. Contrast study was not performed in 11 patients Fig. 1 Location of postoperative leaks in 59 patients according to day of diagnosis Cases of leak GJA (n:40) Pouch (n:6) Exclud Stom (n:2) Y-Y (n:3) Uncertain (n:4) GJA+Pouch (n:2) >10 Day of diagnosis

4 626 OBES SURG (2008) 18: Table 2 Methods used to diagnose leaks in 59 patients according to site Site Drainage CT scan UGS a Clinical criteria alone Gastrojejunal anastomosis (n=40) Gastric pouch (n=6) Jejunojejunal anastomosis (n=3) Excluded stomach (n=2) Gastrojejunal anastomosis + gastric pouch (n=2) Gastric pouch + excluded stomach (n=2) Uncertain (n=4) Total (n=59) a Upper gastrointestinal series (18.6%) because the leaks were already diagnosed by other means. Leaks were asymptomatic at diagnosis in 29 patients (49.2%). The only characteristic sign was discharge or change of secretion through the abdominal drain. Clinical suspicion was confirmed by the oral methylene blue test. In patients who were symptomatic at diagnosis (50.8%), the most frequent clinical manifestations were abdominal pain (50.8%), fever (49.2%), tachycardia (22.0%), nausea and vomiting (18.6%), oliguria (13.6%), and hemodynamic instability with hypotension (11.9%; Table 4). In three patients, anastomotic leak appeared in the immediate postoperative period after reintervention for complications of laparoscopic RYGBP. Of these, two patients underwent laparoscopic gastrostomy because of gastric dilatation, and both procedures were performed on the second postoperative day. In the third patient, reintervention was performed for bleeding, and a gastric pouch leak was diagnosed on postoperative day 7. Eleven patients were transferred to the intensive care unit. Length of hospital stay was significantly longer in patients treated operatively than in those treated nonoperatively. Five patients (8.5%) died, all of whom had undergone surgical reintervention because of leaks. Conservative treatment was used in patients who were hemodynamically stable. The mainstay of this treatment was intravenous antibiotics, monitoring of secretions through drains, and nasoenteral nutrition. Patients with leaks located at the GJA or the gastric pouch underwent digestive endoscopy. A 114-cm-long nasojejunal enteral feeding tube (Flexiflo 8F, Abbott Laboratories, USA) was introduced completely through a pediatric endoscope and was positioned as far away as possible from the leak. The following day, the patients started to receive an enteral formula (Optifast, Novartis, Barcelona, Spain). After 2 or 3 days of receiving this diet, without oral intake, the patients were discharged to home. The drains were left in situ until no drainage was observed. Conservative management was used in 36 patients (61.0%), with total parenteral nutrition, enteral nutrition, or serotherapy with liquids (Table 4). Prophylactic drains detected and controlled anastomotic leaks in 29 of these patients, with minimal morbidity and no major complications. Other major early complications developed in seven of the 36 patients, principally respiratory failure (pleural effusion, pulmonary infections, and atelectasia), subphrenic abscess, and digestive hemorrhage. However, conservative management was successful with complete resolution of the leak in all of these patients except one. This patient underwent laparoscopy to achieve more effective drainage of a subphrenic collection (Table 5). Patients with hemodynamic instability, complicated leaks, or signs of sepsis underwent operative treatment. The mainstay of this treatment was wide and adequate Table 3 Results of routine contrast study using water-soluble contrast (Gastrografin ) performed on postoperative day 1 or 2 in detecting leaks according to site Site Normal Altered Not performed Gastrojejunal anastomosis (n=40) Gastric pouch (n=6) Jejunojejunal anastomosis (n=3) Excluded stomach (n=2) Gastrojejunal anastomosis plus gastric pouch (n=2) Gastric pouch plus excluded stomach (n=2) Uncertain (n=4) Total (n=59) 39 (66.1%) 9 (15.3%) 11 (18.6%)

5 OBES SURG (2008) 18: Table 4 Comparison of clinical characteristics of patients who underwent non-operative versus operative treatment of anastomotic leaks Clinical characteristics Total (n=59) Non-operative (n=36) Operative (n=23) P value Median age (range) 43.0 (18 70) 42.0 (18 70) 44.0 (26 68) Gender (male/female) 20M/39F 13M/23F 7M/16F BMI (kg/m 2 ) median (range) 44.6 ( ) 45.3 ( ) 44.6 ( ) Abdominal pain, n (%) 30 (50.8) 9 (25.0) 21 (91.3) <0.001 Fever (>37.8 C), n (%) 29 (49.2) 17 (47.2) 12 (52.2) Tachycardia (>100 bpm), n (%) 13 (22.0) 1 (2.8) 12 (52.2) <0.001 Vomiting/nausea 11 (18.6) 1 (2.8) 10 (43.5) <0.001 Oliguria (<30 ml/h), n (%) 8 (13.6) 1 (2.8) 7 (30.4) Hypotension, n (%) 7 (11.9) 0 7 (30.4) <0.001 Upper gastrointestinal series indicated leak, n (%) 9 (15.3) 4/32 (12.5) 5/16 (31.3) Diagnosis of leak in <48 h 17 (28.8) 6 (16.7) 11 (47.8) Diagnosis of leak after >48 h 42 (71.2) 30 (83.3) 12 (52.2) Location of the leak, n (%) Gastrojejunostomy 40 (67.8) 29 (80.6) 11 (47.8) Gastric pouch 6 (10.2) 2 (5.6) 4 (17.4) Excluded stomach 2 (3.4) 1 (2.8) 1 (4.3) Jejunojejunostomy 3 (5.1) 0 3 (13.0) Gastrojejunostomy + pouch 2 (3.4) 0 2 (8.7) Pouch + excluded stomach 2 (3.4) 1 (2.8) 1 (4.3) Uncertain 4 (6.8) 3 (8.3) 1 (4.3) drainage and repair of the anastomotic defect when feasible. We proceeded with primary repair if the defect could be easily identified and if local tissues were not severely inflamed. In patients with extensive leaks and complicated course, gastrostomy was performed. Operative treatment was carried out in 23 patients (39.0%). Open surgery (two patients) or the laparoscopic approach (21 patients) was used to control sepsis. At the beginning of our experience with RYGBP, we performed open reinterventions, but currently, the laparoscopic approach is routinely used. Three patients developed a leak from jejunojejunal anastomosis, requiring immediate surgery. The laparoscopic Table 5 Comparison of hospitalization and operative complications in patients who underwent non-operative versus operative treatment of anastomotic leaks Characteristics Total (n=59) Non-operative (n=36) Operative (n=23) P value Hospital readmission, n (%) 34 (57.6) Median length of hospital stay 7.0 (1 29) 5.5 (1 27) 10.0 (3 29) after diagnosis in days (range) Early complications, n (%) n=18 (30.5) n=7 (19.4%) Pulmonary infection and subphrenic abscess (n=2), digestive hemorrhage (n=1), pleural effusion (n=1), pleural effusion and hepatic abscess (n=1), atelectasia (n=1), subphrenic abscess (n=1) n=11 (47.8%) Sepsis with organ dysfunction (n=5), digestive hemorrhage (n=2), pulmonary infection (n=2), pelvic abscess (n=1), subphrenic abscess (n=1) Late complications, n (%) n=19/54 (35.2) n=11 (30.6%) Gastrogastric fistula (n=3), intestinal occlusion (n=1), gastrojejunal anastomotic stricture (n=4), anastomotic ulcer (n=3) n=8/18 (44.4%) Gastrogastric fistula (n=2), gastrojejunal anastomotic stricture (n=3), gastrogastric fistula and gastrojejunal anastomotic stricture (n=1), gastrogastric fistula and anastomotic ulcer (n=1), abdominal wall hernia (n=1) ICU transfer, n (%) 11 (18.6) 2 (5.6) 9 (39.1) Mortality, n (%) 5 (8.5) 0 5 (21.7)

6 628 OBES SURG (2008) 18: approach was used in all of these patients, with resuturing of the jejunojejunal anastomosis and aspiration of the abdominal cavity. None of the patients required a further surgical reintervention. Of these 23 patients, 11 developed additional major complications, and five died of uncontrolled sepsis. Seven patients developed various combinations of congestive heart, respiratory, and renal failure, with different degrees of severity. Of the 54 surviving patients, late complications developed in 19 (35.2%): eight gastrojejunal anastomotic strictures, seven gastrogastric fistulas, four anastomotic ulcers, and one intestinal occlusion, which was surgically resolved (Table 5). Discussion Analysis of our series of patients shows that early diagnosis of anastomotic leaks is paramount, that diagnosis cannot be based on clinical suspicion alone, and that conservative management is effective in hemodynamically stable patients. Overall, of the 11 deaths in our series of 1,200 patients, leak-associated mortality was nearly 50%. Previous studies have reported rates of leak-related deaths to be as high as 37.5%, secondary only to deaths caused by pulmonary emboli [3, 5]. Since intestinal leak was identified as an independent factor related to early death in our series, we tried to identify the factors correlating with the development of this complication. Leaks occurring at the beginning of our experience with gastric bypass were not included in this analysis. At that time, our technique was not fully standardized and the GJA was completely different, with mechanical confection using a linear stapler. The incidence of leaks in our patients decreased from 5.7% among the first 400 patients who underwent laparoscopic RYGBP in our center to 3.7% in the last 400 patients. The five deaths occurred in first 400 patients. In all five of these patients, the leaks were managed surgically. Although no firm conclusions can be drawn from these poor outcomes, we subsequently attempted to manage leaks conservatively, avoiding surgery when feasible. We learned to manage gastrojejunal anastomotic leaks by monitoring through the use of drains and positioning of the nasoenteral tube for adequate feeding. Although the incidence of leak was reduced in the last 400 patients in our series, it still remained high. Previous authors have observed that leaks may continue to occur, even after the learning curve is complete, principally in patients at higher risk for developing leaks, including elderly, super-obese, and male patients, as well as those with multiple comorbidities and previous bariatric operations [3 10]. A possible explanation for our results is that we started to indicate gastric bypass in patients at higher risk, such as men with a higher BMI, patients with multiple serious obesity-related comorbidities, and those requiring revision surgery. In line with previous studies [3, 6, 11], we found that the patients most likely to develop leaks were super-obese men with previous bariatric operations. Male gender was an independent risk factor for leaks in our series. Because men have more central than peripheral obesity and consequently have a greater amount of intraperitoneal and mesenteric fat, the technical difficulty is increased in these patients. Fernandez et al. [3] and Livingston et al. [11] reported that male gender was an independent risk factor for developing leaks and subsequent life-threatening complications. In general, reoperative surgery increases the technical difficulty and risk of complications. Anastomotic leaks have been reported in up to 13% of patients undergoing revision operations, especially after converting a failed vertical banded gastroplasty to RYGBP [3, 5, 11]. Patients in this group might have malnutrition or severe comorbidities that have failed to respond to previous surgical treatments. Additionally, there are other technical difficulties caused by extensive adhesiolysis during reoperation and compromised gastric vascularity because of fibrosis. In this series, revisional surgery was significantly associated with the development of leaks. Moreover, when we analyzed death and leaks according to age above or below 55 years, the incidence of both was significantly higher in patients aged more than 55 years. In our series of 1,200 patients, 79 (6.6%) were aged more than 55 years old. The incidence of both deaths and leaks in older patients was 5.1% compared with 0.6% in younger patients. Whereas some series have shown an increase in mortality with advanced age in bariatric procedures [3, 6], others have not shown a significant rise in either complications or mortality [11]. Despite our findings, we do not believe that advanced age should contraindicate bariatric surgery. The most common site of anastomotic leaks was the gastrojejunostomy. Forty-one patients (69.5%) developed leaks at this site, one of them with an associated leak at the gastric pouch. One of the most challenging steps during laparoscopic RYGBP is construction of the gastrojejunostomy. The optimal anastomosis is tension-free, airtight, and has good vascular supply. Anastomotic tension has been proposed as a risk factor for anastomotic leak after gastric bypass surgery because it may result in stress that exceeds the disruptive pressures of a stapled or sutured anastomosis. One technical factor that has been reported is the role of Roux limb orientation in the development of anastomotic leaks after laparoscopic RYGBP. The retrocolically

7 OBES SURG (2008) 18: routed Roux limb has a more direct path to the gastric pouch and may be associated with less gastrojejunal anastomotic tension. Some studies have reported insignificant differences in the incidence of anastomotic leak after laparoscopic RYGBP with an antecolically versus retrocolically routed Roux limb. This issue is controversial principally because the current literature consists primarily of retrospective and prospective case series. Bertucci et al. [12] reported no leaks after 141 retrocolic and 200 antecolic procedures. Carrasquilla et al. [13] reported a leak rate of 0.1% after 1,000 antecolic procedures versus 1.85% after 108 retrocolic procedures. Similarly, no significant differences in leak rates have been reported between antecolic versus retrocolic laparoscopic RYGBP (0 6.6 versus 0 4.3%) with a linear stapled anastomosis [14]. However, Edwards et al. [15] found postoperative leak rates to be significantly higher after antecolically (3%) versus retrocolically (0.5%) routed Roux limb for laparoscopic RYGBP. Instillation of methylene blue through a nasogastric tube is a current maneuver to evaluate extravasation at the anastomosis. This test is helpful in identifying anastomotic defects that require immediate repair. We were unable to ascertain whether subsequent leaks were at the same site as the anastomotic defect that was repaired during the operation. During the postoperative period, UGS using Gastrografin under fluoroscopy is frequently employed to evaluate the gastrojejunostomy, either routinely or electively. This test permits radiological abnormalities related to the integrity of the GJA, as well as gastrogastric fistulas and delayed gastric pouch emptying, to be detected. In our series, routine use of UGS allowed us to detect leaks in asymptomatic patients or to confirm leaks based on clinical suspicion in 19.9% of patients. However, this test is reported to have low sensitivity because it detects only 22% of documented leaks [14]. Despite this apparent lack of sensitivity, we routinely perform contrast studies. As the morbidity associated with a missed leak is significant, detecting even one otherwise unsuspected leak may justify the use of contrast material. In cases of doubt and to increase the sensitivity of Gastrografin, CT scanning is useful to detect complications after RYGBP. Findings suggestive of an anastomotic leak include contrast extravasation from the gastrojejunostomy or the jejunojejunostomy, collections adjacent to the gastric pouch, diffuse abdominal fluid, and the presence of free intraperitoneal gas. Additional information such as gastric dilatation is also obtained. In 18 patients (30.5%) in our series, a CT scan confirmed the presence of leaks. In four patients, the precise location of the leak was not determined. In our opinion, CT scan appears to be the radiologic procedure of choice to diagnose an anastomotic leak when clinical findings alone are insufficient and the results of UGS are normal. Nonetheless, the sensitivity and specificity of both UGS and CT scan are directly dependent on the radiologist s experience with postoperative anatomical changes after RYGBP. Since we began to perform RYGBP, we have routinely used drains in all patients. We believe that drains positioned near the gastrojejunostomy can be useful in early and small-volume leaks as well as in detecting bleeding. Unless abdominal drains are placed, early leaks will require a new surgical intervention, increasing morbidity. Moreover, reintervention is based on drain placement, and frequently, the repair of the leak may not be feasible especially if there are acute inflammatory changes around the gastrojejunostomy. In 31 patients (52.5%) in our series, early or late diagnosis of leaks was based on discharge of secretions through drains. Thirtyfour patients were readmitted to hospital after discharge with a late diagnosis of leaks. Of these, diagnosis was based on characteristic discharge from drains and positive methylene blue test in 22. In many of our patients, these drains effectively evacuated leaking enteric content, allowing non-operative treatment. In this series, 61.0% patients were managed non-operatively with a high rate of effectiveness, acceptable morbidity, and no mortality. All gastrojejunal, pouch, and excluded stomach leaks in hemodynamically stable patients were managed conservatively, independently of time of onset. Clinical signs and symptoms such as abdominal pain, fever, or tachycardia are not always present in patients who develop leaks, especially those who develop late leaks. In our series, 29 patients (49.2%) were asymptomatic at diagnosis of the leak. The only characteristic sign was discharge or change of secretion from the abdominal drain. The most frequent symptom was abdominal pain, occurring in 50.8%, followed by fever in 49.2%. Clinical studies have described tachycardia as the most sensitive indicator of gastrointestinal anastomotic leak [1, 14]. This sign was observed in only 22.0% of our patients at diagnosis. Of the 17 patients who developed leaks in less than 48 h, only three had tachycardia. We believe that early diagnosis of leaks based on other findings such as discharge through drains and altered UGS, together with immediate treatment, could have influenced the low frequency of this symptom in our series. Operative exploration has been described as the mainstay of treatment for anastomotic leaks in bariatric patients. Hamilton et al. [14] performed open reexploration in all cases of leaks, at which time the abdomen was irrigated, the leaks were repaired, a gastric feeding tube was placed, and closed suction drains were positioned. In contrast, we prefer conservative management of patients with gastro-

8 630 OBES SURG (2008) 18: jejunal leaks, avoiding surgical treatment. Our results support the effectiveness of conservative treatment in hemodynamically stable patients. We believe that the routine use of abdominal drains favors elimination of secretions and early diagnosis, resulting in effective control of leaks and fewer indications for early surgical treatment. In cases of gastrojejunostomy or gastric pouch leaks, early nutrition through a nasoenteral tube is safe [16]. Enteral nutrition has become our preferred route of access in these patients. Initially, we indicated total parenteral nutrition in most patients. However, enteral nutrition presents certain advantages over parenteral nutrition in terms of morbidity and costs. Gonzalez at al. [10] reported that 12% of patients had unsuccessful non-operative treatment and required subsequent operative treatment because of systemic toxicity or poor clinical course. In our series, conservative treatment was unsuccessful in only 1 out of 36 patients; this patient underwent laparoscopy to achieve more effective drainage of a subphrenic collection. Analysis of morbidity and mortality between patients in our series managed operatively or non-operatively presents several limitations. During the period studied, our center lacked a protocol for operative versus non-operative management of anastomotic leaks. Obviously, given the poor results obtained with operative management, our group aims to avoid reintervention in these patients. If surgery is unavoidable, as in cases of jejunojejunal leaks, laparoscopic reoperation is our procedure of choice. Our group is currently evaluating and modifying technical aspects that could decrease the number of reinterventions. In conclusion, anastomotic leaks are a serious complication in patients undergoing gastric bypass for morbid obesity, and efforts must be made to decrease their incidence. Risk factors for anastomotic leaks are age >55 years, male gender, and revisional procedures. The results of the present study suggest that anastomotic leak at the gastrojejunostomy, gastric pouch, or excluded stomach can be managed by conservative methods without the need for reoperation. To obviate the need for reintervention, adequate drainage of the abdominal collection, nutritional support, and rigorous follow-up with imaging studies especially CT scans are essential. Given minimal suspicion of a leak, imaging studies must be performed, as clinical data alone are insufficient grounds for diagnosis. Patients discharged to home must return to the hospital immediately to be evaluated by the surgical team. Given the life-threatening potential of anastomotic leaks, surgeons must always be one step ahead of this complication. References 1. Marshall JS, Srivastava A, Gupta SK, et al. Roux-en-Y gastric bypass leak complications. 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