Gastric leaks post sleeve gastrectomy: Review of its prevention and management

Abstract

Gastric sleeve gastrectomy has become a frequent bariatric procedure. Its apparent simplicity hides a number of serious, sometimes fatal, complications. This is more important in the absence of an internationally adopted algorithm for the management of the leaks complicating this operation. The debates exist even regarding the definition of a leak, with several classification systems that can be used to predict the cause of the leak, and also to determine the treatment plan. Causes of leak are classified as mechanical, technical and ischemic causes. After defining the possible causes, authors went into suggesting a number of preventive measures to decrease the leak rate, including gentle handling of tissues, staple line reinforcement, larger bougie size and routine use of methylene blue test per operatively. In our review, we noticed that the most important clinical sign or symptom in patients with gastric leaks are fever and tachycardia, which mandate the use of an abdominal computed tomography, associated with an upper gastrointrstinal series and/or gastroscopy if no leak was detected. After diagnosis, the management of leak depends mainly on the clinical condition of the patient and the onset time of leak. It varies between prompt surgical intervention in unstable patients and conservative management in stable ones in whom leaks present lately. The management options include also endoscopic interventions with closure techniques or more commonly exclusion techniques with an endoprosthesis. The aim of this review was to highlight the causes and thus the prevention modalities and find a standardized algorithm to deal with gastric leaks post sleeve gastrectomy.

Impact of preoperative body mass index on the final outcome after laparoscopic sleeve gastrectomy for morbid obesity

“…It occurs in up to 5% of patients following LSG (23). In our study leakage from staple line with intra-abdominal collection was seen in six patients (3.4%), which is within the acceptable range.…”

Role of staple line fixation during laparoscopic sleeve gastrectomy

“…14 Abou Rached A et al, had recommended technical tips to reduce gastric leak such as the careful application of ultrasonic devices and staplers, use of larger bougie size, avoiding distal stenosis, and performing intraoperative methylene blue test for immediate detection of leaks. 15 Twist of the gastric remnant after sleeve gastrectomy is a condition similar to the organo-axial gastric volvulus. A twisted or spiral sleeve caused by the progressive rotation of the staple line in an anterior to posterior plane can lead to a functional narrowing despite a fairly normal luminal diameter, and is another cause of symptomatic stenosis.…”

Laparoscopic sleeve gastrectomy for morbid obesity: role of intraluminal and intraperitoneal postoperative drainage

“…Mechanical causes include suture defects due to stapler misfiring or direct tissue injury. Usually they appear within few days (day 1-2) after surgery compared to ischemic causes that usually appear on day 5-6 post-operatively [3]. Aggressive dissection of the posterior attachments of the upper sleeve and thermal injuries to the gastric tube by ultrasonic devices can lead to insufficient vascularization of the gastric tube remnant.…”

“…However, compared to gastric bypass procedures, its complications can be even more severe. Staple line leaks are the most commonly reported complications, ranging in different series between 1% and 3% after primary procedure and more than 10% in revision surgery (3). Based on upper gastrointestinal contrast study, gastric leak can be classified into two types.…”

“…Its success among bariatric surgeons during last 5 years is related to acceptable short-term results in achieving considerable weight loss associated with some advantages of the surgical procedure as in primis lack of digestive anastomosis (2). Bleeding and staple line leak are the most common postoperative complications of LSG (3). The leak rate can vary between 1% and 3% for primary procedure and more than 10% in revision surgery, and the risk of postoperative bleeding has been reported to be between 1% and 6% in different series (1,4).…”