In all likelihood, the true etiology of leaks is a combination of both theories. Damage to tissue during these maneuvers causes weakening and breakdown of the stomach wall, causing leakage. Consequently, leaks tend to occur in the proximal portion of the stomach near the gastroesophageal junction.7–9 Ischemia at the staple line is presumably caused by both the dissection required to release the stomach, combined with the stapling itself. Most patients required multiple interventions with an average of 2.4 interventions per patient. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution.
Although several reports have proposed diagnostic and treatment algorithms for sleeve leakage 3,14, the low number of cases of this complication makes it challenging to generate high-quality, evidence-based reports. Indications, advantages, and disadvantages of less invasive treatment methods for sleeve leakage. Compared to a nasogastric tube, PTEG causes less pain and discomfort and is more beneficial for patients who require long-term tube use. Endoscopic stenting is considered one of the standard treatments for sleeve leakage . However, performing endoscopic treatments such as clipping with OTSC® (see below) or stent placement, as reported in other countries, at the same time may be difficult outside of highly specialized facilities due to the preparation of the devices.
Surgical technique
The management of staple line leaks is complicated by delayed presentation usually after the patient has been discharged.2,8 Initial management is typically determined by computed tomography (CT) imaging and then initial control of sepsis by either percutaneous or laparoscopic drainage.1,8,10,11 Subsequently, patients are managed either surgically or endoscopically based on clinical course. Nonetheless, it is a highly appealing alternative treatment for patients undergoing gastrointestinal surgery who experience postoperative leakage. Csendes et al. classified the timing of sleeve leakage as early (postoperative days 1–3), intermediate (postoperative days 4–7), or late (postoperative days 8 or later), which are sometimes used in the treatment algorithm for sleeve leakage. Endoluminal stenting in select patients can allow for nonoperative management of leaks, without the need for surgery, while at the same time the patients maintain nutritional support of themselves with oral feeding. As secondary aims of this study, we also describe patient symptomatology, the correlation of patient characteristics with a postoperative day of leakage diagnosis, and the management options of anastomotic leaks, through our practice.
- The most common symptom constellation was that of fever with acute abdominal pain and positive Kehr sign, found in 11 (42.3%) patients.
- If these initial techniques fail, reintervention with either endoscopic evaluation or diagnostic laparoscopy should be considered as most patients will require multiple interventions for successful management.
- As such, our patient population was somewhat limited in a specific geographical area, and intraoperative techniques limited to those of our institution.
- One of these patients required additional reoperation with video-assisted thorascopic surgery due to development of persistent left pleural effusion requiring pneumolysis and partial decortication.
Figure 7.
To achieve successful leak closure, it is imperative to prevent disturbances to the distal passage beyond the leakage site. Successful endoscopic closure of the leak using the OTSC® device depends on its ability to suction the relatively healthy tissue surrounding the leak into the cylindrical cap. (b) Schema for the dual use of drainage and nutrition through a single tube. Observation of the leak site using intraoperative endoscopy is useful in determining subsequent treatment strategies.
Several conditions like ischemia, poor surgical technique, stapler failure, high intragastric pressure, and diathermy related organ injury can cause a leak after sleeve gastrectomy . The nasogastric tube was placed on arrival in A&E and removed early at the time of endoscopy and stent placement. Two patients had clinical stability and intra-abdominal abscess and underwent CT guided percutaneous drainage. In the first patient of the series readmitted with a leak, there were septic shock and massive pulmonary embolism, and the drainage of peritoneum was achieved by laparotomy. The mean interval between surgery and readmission for clinical presentation of leak was 13.4 days (range 6–34 days, SD ± 11.85). Psychiatric counselling was conducted with the aim of excluding patients unsuitable for surgery due to mental health contraindications .
Table 1.
High-quality data from RCTs have shown no statistically significant difference in anastomotic dehiscence in patients with and without intra-abdominal drains, as the current trend recommends the use of intra-abdominal drains only in complicated or revisional cases. Patient risk factors that are found in the literature to significantly contribute to leakage rates, include male sex, BMI of more than 50 daman game app kg/m2, use of SG as a revision procedure, and presence of sleep apnea 36,37,38. Experienced surgeons also seem to agree that another cause of postoperative leaks is the creation of an ischemic environment on the staple line, particularly close to and around the angle of His. The mechanics of staple line leakage, include a long stapling line being present, as well as the conversion of the stomach itself into a narrow, high-pressure tube due to the presence of both esophageal and pyloric sphincters. Our study focused on acute and early leaks, with a few reports on late and chronic leaks that are largely thought to be governed by different pathophysiological principles. Single-institution studies are consistently producing contradictory results either in favor of or indifferent towards increased leak rates with narrower bougie sizes 25,26.
Multiple retrospective studies have further evaluated staple-line reinforcement, with the largest study published to date utilizing the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program data base . Since its early days of adoption, the complication of staple-line leak remains the greatest concern with the reported leak rates averaging 2.4% and ranging from 1.1 to 4.7% 3–8. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. Endoscopic stenting after staple line leaks has been supported by many authors in recent years 16–18, even if this is not a widely accepted treatment.
Our study is not immune to certain shortcomings, as with any original report. One such approach is the complex laparoscopic Roux-en-Y fistulojejunostomy formation usually performed for complex, chronic fistulas after a SG leak . Advanced surgical options after conservative, endoscopic, or minimally invasive approaches have failed are also being performed in experienced bariatric centers. Addition of laparoscopic assistance forms the rendezvous procedure, during which the laparoscopic surgeon assists in accurate identification of the defect and placement of the suction device which is guided at the same time by the endoscopist . Open-pore suction devices can be placed endoscopically at the endoluminal fistula opening . Despite lacking large-scale trials, the literature suggests high success rates with minimal to no adverse effects 50,59,60.
This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. This systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Staple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Based on our experience, we suggest the following flow chart for the treatment of staple line acute and early leaks after LSG.
- Single-institution studies are consistently producing contradictory results either in favor of or indifferent towards increased leak rates with narrower bougie sizes 25,26.
- This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement.
- EGD evaluation demonstrated distal stricture requiring dilation, which was a likely contributor to the development of late staple line leak secondary to increased intraluminal pressure.
Treatments of Sleeve Leakage
When comparing the leak rates from the current analysis to the previous review, it is interesting to note the reliability of the data between both studies . At least one of the three patient characteristics variables (age, gender, or starting BMI) were reported in all but the following eight studies representing 12,473 patients 24, 28, 49, 63, 76, 97, 144. Analysis objectives centered on 5 reinforcement methods NO–SLR, suture, BPM, tissue sealant seal, APM and the number of patients with leak and without leak; bleeding, overall complications, and mortality were collected as text fields but not categorically summarized. Full-text articles were included only if an LSG procedure, leak data, and type of staple-line reinforcement were reported.
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The extent of the abscess cavity (size and spread) can also affect subsequent treatment strategies; therefore, contrast-enhanced CT scans are ideal if renal function allows . However, there have been instances where reoperation was necessary after multiple treatment interventions . Therefore, understanding the pathogenesis and treatment options for this complication is crucial. Study data are available after request to the authors and appropriate clearance from the Bioethics Committee of the General University Hospital of Patras.
Table 5.
The treatment of patients who develop leakages requires a multidisciplinary team. In our experience, all patients were discharged home in good clinical conditions, with the leak being diagnosed several days after surgery, as confirmed by Sethi et al. in a report of 1762 LSGs. Only one of the patients with leak (16.67%) had staple line reinforcement during surgery. We record 1 acute leak (presentation 6 days after sleeve gastrectomy) and 5 early leaks (presentation 7–34 days after surgery). At postoperative day (POD) 2, all patients underwent a radiological upper gastrointestinal series, and in absence of leakage they started a liquid diet and the drain was removed. In this study, we focused on staple line leaks, based on data collected and recorded on a prospective database.
Table 1.
The entirety of the reported leaks were reported in the cardio-esophageal junction area. The utility of abnormal drain amylase levels as a diagnostic modality in staple line leaks. After a clinical suspicion of postoperative leak was established, the patient underwent a double-contrast CT scan, which is known to be the most sensitive identifier of a postoperative leak. A leak was suspected, based on the patient’s clinical presentation in the immediate and early postoperative period, and the serial, routine monitoring of drain amylase levels.
Initially, all patients will be diagnosed on CT imaging; types of intervention then depend on the patient’s stability, regardless of timing of presentation, as illustrated in Figure 1. Another method utilized at our institution was OTSC, which was utilized in four patients but only as the last intervention in one patient. At our institution, we have used various methods reported in the literature to mitigate staple line leak. The longest recovery time was three months in a patient treated with E-Vac sponges whose course was complicated by acute respiratory failure requiring percutaneous tracheostomy placement for ventilatory weaning.
It is important to acknowledge that leaks following LSG present distinct challenges compared to other gastrointestinal surgical complications. There is no established timing for revisional surgery; however, if conservative treatments fail, decisions should be made before the local chronic inflammation progresses to reduce the difficulty of surgery. Therefore, local drainage and enteral nutrition should be prioritized during all stages of treatment. However, the patient’s overall condition should be stabilized as much as possible before surgery. Careful consideration is necessary when determining the timing of treatment evaluation because continuing ineffective treatment may negatively impact patient outcomes.
We describe here our experience over 10 years with the management of gastric leaks in a series of patients submitted to a primary LSG, trying to draw a final flow chart based on our findings. Aim of the study was trying to draw a final flow chart for the management of gastric leaks after laparoscopic sleeve gastrectomy, based on the review of our cases over 10 years‘ experience. In the long term, patients are either managed endoscopically or surgically for staple line leaks.