Pigtails Internal Drainage for 2-cm Gastric Leak After Sleeve Gastrectomy Prolongs Healing

Abstract

We would like to thank Donatelli et al. for the opportunity to comment on his complicated case report of a leak after laparoscopic sleeve gastrectomy (LSG) with a 2-cm-long dehiscence. We would like to make some remarks.In the selected case presented, a dehiscence of 2 cm is unusual and the technique used for the initial laparoscopic sleeve gastrectomy (LSG) must be questionable. A description of the initial procedure is suitable, describing the technique of dissection, the bougie size, the type of stapling, and the reinforcement used. Such a large defect can be explained by necrosis which occurred after dissection, by mischoice of stapling device, or/and poor choice of reinforcement type.The gastric leak healed by pigtails approach (although some may re-opened at a later date), but no details about the presence of gastric stenosis was mentioned. A twisted, poorly constructed sleeve will add insult to the injury and it necessitates the deployment of an endoscopic stent. Still the patient needed seven endoscopic sessions and 206 days to close the leak. In our proposed algorithm [1], for patients with gastric stenosis treated with tailored approach and endoscopic stent, the leaks achieved complete healing after an average duration of 118 days (a 75 % reduction in time). This difference of the healing time is increasing cost and patients' sufferance unnecessarily.The occurrence of a gastropleural fistula could also be explained by the presence of a concomitant hiatal hernia misrecognized during the initial procedure. If this was the case, it should have been operated contemporaneously and the gastropleural fistula could have been avoided. The OVESCO® clip (OTSC®; ) in this setting was, in fact, contraindicated.The authors Bbelieve^that in their experience, the stents will increase the local ischemia and subsequently increase leak in size. We do not agree with the statement that stents cause ischemia, as no recent data in the literature [2, 3] supports it.The debate on the algorithm regarding the leak size when no stenosis is associated will remain open. Most centers are proposing, for all types of leaks after LSG, an endoscopic stent [4,5]. The main purpose of the algorithm with our early experience of 19 cases was to change this dogma and to offer patients with this dreaded complication after LSG, a tailored approach. We remain unconvinced that pigtail drains represent a solution for all the types of leak, irrespective of leak size, and we are waiting for a new updated manuscript with all 200 cases from the authors. References1. Nedelcu M, Manus T, Cotirlet A et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. 2. Shim CN, Kim HI, Hyung WJ, et al. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc. 2014;28(3):833-40. 3. Alazmi W, Al-Sabah S, Ali DA, et al. Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature. ...

Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy

“…Based on these data and the experience reported in other series, a DPS should be considered as the standard for management of gastric leak after sleeve gastrectomy. A CS (or combined CS and DPS) should be reserved for poor indications for DPS, such as gastric leak associated with gastric stenosis or large gastric leak measuring more than 2 cm in diameter.…”

“…For these reasons, a DPS is now becoming the standard for the treatment of gastric leak. However, such stents may sometimes fail to heal the gastric leak, particularly in the presence of a large fistula orifice or in the event of gastric stenosis below the fistula orifice. In the latter situation, the use of a CS alone or in combination with a DPS, is required to treat the gastric stenosis at the same time as the gastric leak.…”