Percutaneous drainage of abscesses due to sleeve gastrectomy for morbid obesity. Initial experience.

Transcription

1 Percutaneous drainage of abscesses due to sleeve gastrectomy for morbid obesity. Initial experience. Poster No.: C-0176 Congress: ECR 2011 Type: Scientific Exhibit Authors: M. Kelogrigoris 1, E. Sotiropoulou 2, K. Stathopoulos 1, V. Georgiadou 1, P. Philippousis 1, L. Thanos 1 ; 1 Athens/GR, 2 ATHENS/GR Keywords: DOI: Abscess, Drainage, Percutaneous, CT, Interventional nonvascular, Abdomen /ecr2011/C-0176 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 13

2 Purpose Bariatric surgery is considered the only effective long-term treatment of morbid obesity.among the different procedures, laparoscopic sleeve gastrectomy (LSG) is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity.it is effective in achieving 60-70% excess weight loss by 3 years. Despite its promising results, LSG has been reported to have several complications.the most important of them is gastric leak from the staple sleeve line which causes the creation of infected abdominal collections.because these patients present with signs of sepsis, the drainage of the infected collections is a great priority. CT- guided percutaneous drainage can be a good alternative choice in the management of patients with infected abdominal collections. We report our experience with 21 patients with abdominal infected collections due to gastric leak after laparoscopic sleeve gastrectomy for morbid obesity over a 30-month period, which were managed with CT-guided percutaneous drainage. Methods and Materials The medical and radiological files of all patients with infected collections due to gastric leak after laparoscopic sleeve gastrectomy who underwent percutaneous drainage under CT guidance from 1/1/2007 to 30/6/2009 at Computed Tomography and Interventional Radiology Department of Sotiria General Hospital of Chest Diseases, Athens, Greece. The study was approved by the appropriate ethical committees of the hospital and all the patients that were included, gave informed consent to the work. Twenty one patients with infected abdominal collections-abscesses- were included, all diagnosed by computed tomography with intravenous contrast media.the results were reviewed retrospectively. All the patients presented with leaks within 1 week of surgery and had persistent sepsis 1 week after initiation of antibiotic therapy. Sepsis was defined as fever>38 C with increased white blood cells count, tachycardia>100 beats per minute and a rising C- reactive protein. All procedures were performed with pigtail catheter chest tubes (8F to 12 F). The size of the catheter depended on the maximum transverse diameter of the abscesses. A direct trocar method was usually used for tube insertion, after the puncture site was sterilized and anesthetized; however, a modified Seldinger technique was also used in some cases when there was difficulty in the accurate placement of the catheter. For the modified Seldinger,once the puncture site was sterilely prepared and anesthetized, 18- gauge lumbar puncture needle was placed through the abdominal wall into the abscess cavity and aspiration of pus confirmed the adequate positioning of the needle. A Page 2 of 13

3 guide wire was then introduced through the needle. Serial dilation and pigtail catheter insertion were performed using the guide wire. The catheter was secured in the place by suturing. Flushing the tube with 15 ml of sterile saline three times daily was usually prescribed to assure patency of the tube. After the procedure, repeat axial images of CT scan were taken to confirm the correct catheter placement. Day-to-day follow-up of the patient was usually done by the referring physician, including clinical observations, daily tube output measurements and, when necessary, repeated computed tomography with contrast media. Catheter was left in place until drainage (pus or gastrointestinal content) was stopped. Patients were followed till complete closure of the abscess cavity or decision for surgery was taken due to non closure of abscess cavity. Success of chest tube drainage was defined as complete closure of the abscess cavity with clinical improvement and avoidance of surgical drainage (open or laparoscopic) (fig.1-3) Images for this section: Page 3 of 13

4 Fig. 1: CT scan shows an infected fluid collection between the liver and the spleen in a 26-year obese woman who had underwent sleeve gastrectomy. Page 4 of 13

5 Fig. 2: CT-guided percutaneous drainage of the infected abdominal collection. Page 5 of 13

6 Fig. 3: CT scan after percutaneous drainage shows immediate decrease in the amount of fluid of the collection. The patient had a rapid symptomatic response to drainage. Page 6 of 13

7 Results Nine patients were male and twelve female. The age range was years (mean age 39,2 years). The decision for the drainage was made due to persistent fever and leucocytosis 1 week after initiation of antibiotic therapy. Immediate technical success was achieved in all the 21 patients(fig.1-4). We used the Seldinger technique for tube insertion in seven patients. The direct trocar technique was used in fourteen cases. Overall we used five 8F, ten 10F and six 12F pigtail catheters for the drainage of the abscesses. All the 21 patients showed clinical improvement with resolution of sepsis symptoms (regression of fever, decrease of white blood cell count). Three of them needed extra surgical management while the rest eighteen patients avoided it. Thus the success rate of the procedure was 86% (18/21). These three patients, despite their initial clinical improvement after the drainage, were readmitted a few days later due to left upper quadrant pain and nausea. They all were diagnosed to have recurrence of the infected abdominal collection due to gastric leak with contrast enhanced-ct and they all needed laparoscopic re-exploration, one of which was converted to open surgery. The patient who needed extra open surgery, postoperatively developed acute respiratory distress syndrome (ARDS),underwent several other procedures includind re-explorations and died a few weeks later. The other two patients were found to have controlled fistulas and were managed by use of covered stents. Among the eighteen patients who avoided surgery, two needed replacement of the catheter due to obstruction. None of all the 21 patients developed pneumothorax, hemothorax, abdominal bleeding, peritonitis, abdominal wall hematoma or intestinal injury. The average length of stay of the drainage catheter for the eighteen patients who needed no further surgical management was 7 weeks. Images for this section: Page 7 of 13

8 Fig. 1: CT scan shows an infected fluid collection between the left lobe of the liver and the spleen in a 44-year obese man who had underwent sleeve gastrectomy. Page 8 of 13

9 Fig. 2: CT-guided percutaneous drainage of the infected abdominal collection. Page 9 of 13

10 Fig. 3: CT-guided percutaneous drainage of the infected abdominal collection. Page 10 of 13

11 Fig. 4: CT scan after percutaneous drainage shows immediate decrease in the size of the abscess. The patient had a rapid symptomatic response to drainage. Page 11 of 13

12 Conclusion CT-guided percutaneous catheter drainage is an effective and safe procedure for the management of infected abdominal collections due to gastric leak after laparoscopic sleeve gastrectomy and should be considered both as a preparatory step for surgery and a valuable alternative to open or laparoscopic surgery. Failure of the procedure does not, however, preclude a subsequent surgical operation. References 1. Busetto L, Mirabelli D, Petroni ML, et al. Comparative long-term mortality after laparoscopic adjustable gastric banding versus nonsurgical controls. Surg Obes Relat Dis 2007;3: Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240: Deitel M, Crosby RD, Gagner M. The first international consensus summit for sleeve gastrectomy (SG), New York City, October 25-27, Obes Surg. 2008;18: Haslam DW, James WP (2005). "Obesity". Lancet 366 (9492): Must A, Spadano J, Coakley EH et al (1999) The disease burden associated with overweight and obesity. JAMA 282(16): Overweight, obesity, health risk: National Task Force on the prevention and treatment of obesity (2000) Arch Intern Med 160: North American Association for the study of obesity (NAASO), the National Heart (1998) Clinical Guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. National Institutes of Health, Bethesda, MD, NIH publication Barness LA, Opitz JM, Gilbert-Barness E (December 2007). "Obesity: genetic, molecular, and environmental aspects". Am. J. Med. Genet. A 143A (24): Goodrick GK, Poston WS 2nd, Foreyt JP (1996) Methods for voluntary weight loss and control: update Nutrition 12: Sjostrom L, Lendroos A, Peltonen M et al (2004) Lifestyle,diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 351(26): Pories WJ, Swanson MS, MacDonald KG et al (1995) Who would have thought it? An operation proves to be the most effective therapy for adultonset diabetes mellitus. Ann Surg 222: Maggard MA, Shugarman LR, Suttorp M et al (2005) Metaanalysis: surgical treatment of obesity. Ann Intern Med 142(7): Page 12 of 13

13 13. Buchwald H, Avidor Y, Braunwald E et al (2004) Bariatric surgery,a systematic review and meta-analysis. JAMA 292: Oluseun AS, Yood SM, Courtney J et al (2007) Natural history of morbid obesity without surgical intervention. Surg Obes Relat Dis 3: Busetto L, Mirabelli D, Petroni ML et al (2007) Comparative long-term mortality after laparoscopic adjustable gastric banding versus nonsurgical controls. Surg Obes Relat Dis 3(5): Adams TD, Gress RE, Smith SC et al (2007) Long-term mortality after gastric bypass surgery. N Engl J Med 357(8): Hamoui N, Anthone GJ, Kaufman HS, Crookes PF (2006) Sleeve gastrectomy in the high-risk patient. Obes Surg 16: Moon Han S, Kim WW, Oh JH (2005) Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 15: Braghetto I, Korn O, Valladares H et al (2007) Laparoscopic sleeve gastrectomy: surgical technique, indications and clinical results. Obes Surg 17: Roa PE, Kaidar-Person O, Pinto D et al (2006) Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcome. Obes Surg 16: Jacobs M et al. Laparoscopic sleeve gastrectomy: a retrospective review of 1- and 2-year results.surg Endosc Apr;24(4): Epub 2009 Aug 19 Personal Information Page 13 of 13