CT Fluoroscopy-Guided Drain Placement to Treat Infected Gastric Leakage after Sleeve Gastrectomy: Technical and Clinical Outcome of 31 Procedures

Abstract

Purpose To observe the technical and clinical outcome as well as safety of CT fluoroscopy-guided drain placement in the multimodal clinical complication management of superinfected gastric leakage after sleeve gastrectomy.

Materials and Methods All consecutive patients who underwent CT fluoroscopy-guided drain placement to treat superinfected postoperative leakage after sleeve gastrectomy in our department between 2007 and 2014 were included in this retrospective study. All interventions were performed on a 16- or 128-row CT scanner under intermittent CT fluoroscopy guidance (15–25 mAs, 120 kV). The technical and clinical success rates as well as complications, additional therapies and patient radiation dose were analyzed.

Results 14 patients (mean age: 43.8 ± 11.3 years, mean BMI: 52.9 ± 13.5, 7 women) who underwent a total of 31 CT fluoroscopy-guided drain placement procedures were included. 30 of 31 interventions (96.8 %) were technically successful. 7 patients underwent more than one intervention due to drain obstruction or secondary dislocation or as further treatment. During and after the intervention no procedure-associated complications occurred. In all patients, inflammation parameters decreased within days after the CT-guided intervention. The total interventional dose length product (DLP) was 1561 ± 1035 mGy*cm.

Conclusion CT fluoroscopy-guided drain placement has been shown to be a safe minimally invasive procedure that rarely leads to complications for treating superinfected gastric leakage occurring after sleeve gastrectomy. We assume that operative revisions in a high-risk patient group can be avoided using this procedure.

Key Points: 

• CT fluoroscopy-guided drain placement in obese – often medically highly complex – patients is a technically feasible procedure.

• Multimodal treatment (CT intervention, endoscopy and surgery) is required to successfully treat gastric leakage after bariatric surgery.

• High-risk surgery might be avoided by the CT-guided drain placement.

Citation Format

• Schwarz J, Strobl FF, Paprottka PM et al. CT Fluoroscopy-Guided Drain Placement to Treat Infected Gastric Leakage after Sleeve Gastrectomy: Technical and Clinical Outcome of 31 Procedures. Fortschr Röntgenstr 2020; 192: 163 – 170

Zusammenfassung

Ziel In dieser Studie wurden die technischen und klinischen Ergebnisse sowie die Sicherheit von CT-fluoroskopisch gesteuerten Drainageneinlagen in entzündete Verhalte bei Nahtinsuffizienz nach Sleeve-Gastrektomien als Teil eines multimodalen Komplikationsmanagements evaluiert.

Material und Methoden In diese retrospektive Studie wurden alle Patienten eingeschlossen, die zwischen 2007 und 2014 in unserer Abteilung eine CT-fluoroskopisch gesteuerte Drainageneinlage in entzündete Verhalte nach Sleeve-Gastrektomien erhalten haben. Alle Interventionen wurden auf einem 16- oder 128-Zeilen-CT unter intermittierender Fluoroskopie (15–25 mAs, 120 kV) durchgeführt. Technischer und klinischer Erfolg, die Patientenstrahlendosis (DLP), die Komplikationsrate und ergänzende Therapien wurden analysiert.

Ergebnisse 14 Patienten (Altersdurchschnitt 43,8 ± 11,3 Jahre, BMI 52,9 ± 13,5, 7 Frauen) wurden eingeschlossen, die insgesamt 31 CT-fluoroskopisch gesteuerte Drainagen erhalten haben. 30 der 31 Interventionen (96,8 %) waren technisch erfolgreich. Sieben Patienten erhielten mehr als eine Intervention aufgrund einer Drainageobstruktion, sekundärer Dislokationen oder als Verlaufstherapie. Peri- und postinterventionell traten keine interventionsbedingten Komplikationen auf. Bei allen Patienten fielen die laborchemischen Entzündungsparameter innerhalb von Tagen nach der Intervention. Das durchschnittliche gesamte Dosislängenprodukt einer Intervention lag bei 1561 ± 1035 mGy*cm.

Schlussfolgerung CT-fluoroskopisch gesteuerte Drainageneinlagen sind sichere, minimalinvasive und komplikationsarme Interventionen, um infizierte Verhalte nach Nahtinsuffizienzen bei Sleeve-Gastrektomien zu therapieren. Wir gehen davon aus, dass durch diese Interventionen komplexe Revisionsoperationen bei Hochrisikopatienten vermieden werden können.

Kernaussagen: 

• CT-fluoroskopisch gesteuerte Drainageneinlagen bei adipösen, oft multimorbiden Patienten sind eine technisch gut durchführbare Intervention.

• Eine multidisziplinäre Behandlung (CT-Intervention, Endoskopie und Chirurgie) ist notwendig, um Nahtinsuffizienzen nach bariatrischer Chirurgie erfolgreich zu therapieren.

• Hochrisiko-Revisionsoperationen könnten in vielen Fällen durch CT-gesteuerte Drainageneinlagen verhindert werden.

Key words

gastric leakage - drainage - fluoroscopy - sleeve gastrectomy

• References

• 1 Hammond RA, Levine R. The economic impact of obesity in the United States. Diabetes, metabolic syndrome and obesity: targets and therapy 2010; 3: 285-295 . doi:10.2147/DMSOTT.S7384
• 2 Finucane MM, Stevens GA, Cowan MJ. et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 2011; 377: 557-567 . doi:10.1016/S0140-6736(10)62037-5
• 3 Johnson W, Li L, Kuh D. et al. How Has the Age-Related Process of Overweight or Obesity Development Changed over Time? Co-ordinated Analyses of Individual Participant Data from Five United Kingdom Birth Cohorts. PLoS medicine 2015; 12: e1001828 . doi:10.1371/journal.pmed.1001828
• 4 Organization WH. Global Status Report on Noncommunicable Diseases 2014. World Health Organization; 2015
• 5 Debs T, Petrucciani N, Kassir R. et al. Trends of bariatric surgery in France during the last 10 years: analysis of 267466 procedures from 2005–2014. Surgery for obesity and related diseases: official journal of the American Society for Bariatric Surgery 2016;
• 6 Sarkhosh K, Birch DW, Sharma A. et al. Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide. Canadian journal of surgery Journal canadien de chirurgie 2013; 56: 347-352
• 7 Winfield RD, Reese S, Bochicchio K. et al. Obesity and the Risk for Surgical Site Infection in Abdominal Surgery. The American surgeon 2016; 82: 331-336
• 8 Tjeertes EK, Hoeks SE, Beks SB. et al. Obesity – a risk factor for postoperative complications in general surgery?. BMC anesthesiology 2015; 15: 112 . doi:10.1186/s12871-015-0096-7
• 9 Slim R, Smayra T, Chakhtoura G. et al. Endoscopic stenting of gastric staple line leak following sleeve gastrectomy. Obesity surgery 2013; 23: 1942-1945 . doi:10.1007/s11695-013-1072-2
• 10 Simon F, Siciliano I, Gillet A. et al. Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time. Obesity surgery 2013; 23: 687-692 . doi:10.1007/s11695-012-0861-3
• 11 Shehab HM, Hakky SM, Gawdat KA. An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video). Obesity surgery 2016; 26: 941-948 . doi:10.1007/s11695-015-1857-6
• 12 Sakran N, Goitein D, Raziel A. et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2834 patients. Surgical endoscopy 2013; 27: 240-245 . doi:10.1007/s00464-012-2426-x
• 13 Casella G, Soricelli E, Rizzello M. et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obesity surgery 2009; 19: 821-826 . doi:10.1007/s11695-009-9840-8
• 14 Soufron J. Leak or Fistula After Sleeve Gastrectomy: Treatment with Pigtail Drain by the Rendezvous Technique. Obesity surgery 2015; 25: 1979-1980 . doi:10.1007/s11695-015-1804-6
• 15 Csendes A, Braghetto I, Leon P. et al. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2010; 14: 1343-1348 . doi:10.1007/s11605-010-1249-0
• 16 Kelogrigoris M, Sotiropoulou E, Stathopoulos K. et al. CT-guided percutaneous drainage of infected collections due to gastric leak after sleeve gastrectomy for morbid obesity: initial experience. Cardiovascular and interventional radiology 2011; 34: 585-589 . doi:10.1007/s00270-010-9928-5
• 17 Corona M, Zini C, Allegritti M. et al. Minimally invasive treatment of gastric leak after sleeve gastrectomy. La Radiologia medica 2013; 118: 962-970 . doi:10.1007/s11547-013-0938-7
• 18 Paprottka PM, Helmberger T, Reiser MF. et al. Computed tomography guidance: fluoroscopy and more. Der Radiologe 2013; 53: 974-985 . doi:10.1007/s00117-012-2460-7
• 19 Sarti M, Brehmer WP, Gay SB. Low-dose techniques in CT-guided interventions. Radiographics: a review publication of the Radiological Society of North America, Inc 2012; 32: 1109-1119 . doi:10.1148/rg.324115072
• 20 Aberle D, Charles H, Hodak S. et al. Optimizing care for the obese patient in interventional radiology. Diagnostic and interventional radiology 2017;
• 21 Uppot RN. Impact of obesity on radiology. Radiologic clinics of North America 2007; 45: 231-246 . doi:10.1016/j.rcl.2007.03.001
• 22 Riaz RM, Myers DT, Williams TR. Multidetector CT imaging of bariatric surgical complications: a pictorial review. Abdominal radiology 2016; 41: 174-188 . doi:10.1007/s00261-015-0604-8
• 23 Gnannt R, Fischer MA, Baechler T. et al. Distinguishing infected from noninfected abdominal fluid collections after surgery: an imaging, clinical, and laboratory-based scoring system. Investigative radiology 2015; 50: 17-23 . doi:10.1097/rli.0000000000000090
• 24 Trumm GC, Hoffmann RT. CT-Guided Biopsy and Drainage. In: Reiser FM, Becker CR, Nikolaou K. et al. Hrsg Multislice CT. Berlin, Heidelberg: Springer Berlin Heidelberg; 2009: 511-534 . doi:10.1007/978-3-540-33125-4_37
• 25 Wallace MJ, Chin KW, Fletcher TB. et al. Quality improvement guidelines for percutaneous drainage/aspiration of abscess and fluid collections. Journal of vascular and interventional radiology: JVIR 2010; 21: 431-435 . doi:10.1016/j.jvir.2009.12.398
• 26 Kaufman JA, Lee MJ. Vascular and Interventional Radiology: The Requisites. 2nd. Edition Elsevier – Health Sciences Division; 2013
• 27 Filippiadis DK, Binkert C, Pellerin O. et al. Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System. Cardiovascular and interventional radiology 2017; 40: 1141-1146 . doi:10.1007/s00270-017-1703-4
• 28 Joemai RMS, Zweers D, Obermann WR. et al. Assessment of Patient and Occupational Dose in Established and New Applications of MDCT Fluoroscopy. American Journal of Roentgenology 2009; 192: 881-886 . doi:10.2214/ajr.08.1765
• 29 Kloeckner R, Santos D, Schneider J. et al. Radiation exposure in CT-guided interventions. European journal of radiology 2013; 82: 2253-2257 . doi:10.1016/j.ejrad.2013.08.035
• 30 Bamberg F, Marcus R, Petersilka M. et al. Challenges for computed tomography of overweight patients. Der Radiologe 2011; 51: 366-371 . doi:10.1007/s00117-010-2087-5
• 31 Uppot RN, Sahani DV, Hahn PF. et al. Effect of obesity on image quality: fifteen-year longitudinal study for evaluation of dictated radiology reports. Radiology 2006; 240: 435-439 . doi:10.1148/radiol.2402051110