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Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients

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Abstract

Background

Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak.

Methods

Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters.

Results

Among the 2,834 patients who underwent LSG, 44 (1.5 %) with gastric leaks were identified. Of these 44 patients, 30 (68 %) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m2. Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3 %) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0–2 days) in nine cases (20 %), intermediately (3–14 days) in 32 cases (73 %), and late (>14 days) in three cases (7 %). For 38 patients (86 %), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84 %), 11 (50 %), and 9 (60 %) of these patients. Reoperation was performed for 27 of the patients (61 %). Other treatment methods included percutaneous drainage (n = 28, 63.6 %), endoscopic placement of stents (n = 11, 25 %), clips (n = 1, 2.3 %), and fibrin glue (n = 1, 2.3 %). In 33 of the patients (75 %), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2–270 days), and the overall leak-related mortality rate was 0.14 % (4/2,834).

Conclusion

Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.

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References

  1. Arias E, Martinez PR, Ka Ming Li V et al (2009) Midterm follow-up after sleeve gastrectomy as a final approach for morbid obesity. Obes Surg 19:544–548

    Article  PubMed  Google Scholar 

  2. Atkins ER, Preen DB, Jarman C et al (2012) Improved obesity reduction and comorbidity resolution in patients treated with 40-French bougie versus 50-French bougie four years after laparoscopic sleeve gastrectomy: analysis of 294 patients. Obes Surg 22:97–104

    Article  PubMed  Google Scholar 

  3. Aurora AR, Khaitan L, Saber AA (2011) Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 26(6):1509–1515

    Article  PubMed  Google Scholar 

  4. Baltasar A, Serra C, Perez N et al (2005) Laparoscopic sleeve gastrectomy: a multipurpose bariatric operation. Obes Surg 15:1124–1128

    Article  PubMed  Google Scholar 

  5. Baltasar A, Serra C, Perez N et al (2006) Re-sleeve gastrectomy. Obes Surg 16:1535–1538

    Article  PubMed  Google Scholar 

  6. Baltasar A, Bou R, Bengochea M et al (2007) Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy. Obes Surg 17:1408–1410

    Article  PubMed  Google Scholar 

  7. Bellanger DE, Greenway FL (2011) Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 21:146–150

    Article  PubMed  Google Scholar 

  8. Bertucci W, White S, Yadegar J et al (2006) Routine postoperative upper gastroesophageal imaging is unnecessary after laparoscopic Roux-en-Y gastric bypass. Am Surg 72:862–864

    PubMed  Google Scholar 

  9. Burgos AM, Braghetto I, Csendes A et al (2009) Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg 19:1672–1677

    Article  PubMed  Google Scholar 

  10. Casella G, Soricelli E, Rizzello M et al (2009) Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 19:821–826

    Article  CAS  PubMed  Google Scholar 

  11. Clinical Issues Committee of American Society for Metabolic and Bariatric Surgery (2007) Sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis 3:573–576

    Article  Google Scholar 

  12. Conio M, Blanchi S, Repici A et al (2010) Use of an over-the-scope clip for endoscopic sealing of a gastric fistula after sleeve gastrectomy. Endoscopy 42(Suppl 2):E71–E72

    Article  PubMed  Google Scholar 

  13. Cottam D, Qureshi FG, Mattar SG et al (2006) Laparoscopic sleeve gastrectomy as an initial weight loss procedure for high-risk patients with morbid obesity. Surg Endosc 20:859–863

    Article  CAS  PubMed  Google Scholar 

  14. Court I, Wilson A, Benotti P et al (2010) T-tube gastrostomy as a novel approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case report and review of the literature. Obes Surg 20:519–522

    Article  PubMed  Google Scholar 

  15. Csendes A, Braghetto I, Leon P et al (2010) Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg 14(9):1343–1348

    Article  PubMed  Google Scholar 

  16. Dallal RM, Bailey L, Nahmias N (2007) Back to basics—clinical diagnosis in bariatric surgery: routine drains and upper GI series are unnecessary. Surg Endosc 21:2268–2271

    Article  PubMed  Google Scholar 

  17. Dapri G, Cadiere GB, Himpens J (2009) Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy. Surg Obes Relat Dis 5:72–76

    Article  PubMed  Google Scholar 

  18. Dapri G, Cadiere GB, Himpens J (2009) Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg 20:462–467

    Article  PubMed  Google Scholar 

  19. Daskalakis M, Berdan Y, Theodoridou S et al (2011) Impact of surgeon experience and buttress material on postoperative complications after laparoscopic sleeve gastrectomy. Surg Endosc 25:88–97

    Article  PubMed  Google Scholar 

  20. Deitel M, Crosby RD, Gagner M (2008) The first international consensus summit for sleeve gastrectomy (SG), New York, October 25–27, 2007. Obes Surg 18:487–496

    Article  PubMed  Google Scholar 

  21. Elazary R, Hazzan D, Appelbaum L et al (2009) Feasibility of sleeve gastrectomy as a revision operation for failed silastic ring vertical gastroplasty. Obes Surg 19:645–649

    Article  PubMed  Google Scholar 

  22. Foletto M, Prevedello L, Bernante P et al (2009) Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis 6:146–151

    Article  PubMed  Google Scholar 

  23. Gagner M (2010) Leaks after sleeve gastrectomy are associated with smaller bougies: prevention and treatment strategies. Surg Laparosc Endosc Percutan Tech 20:166–169

    Article  PubMed  Google Scholar 

  24. Gagner M, Deitel M, Kalberer TL et al (2009) The Second international consensus summit for sleeve gastrectomy, March 19–21, 2009. Surg Obes Relat Dis 5:476–485

    Article  PubMed  Google Scholar 

  25. Goitein D, Goitein O, Feigin A et al (2009) Sleeve gastrectomy: radiologic patterns after surgery. Surg Endosc 23:1559–1563

    Article  PubMed  Google Scholar 

  26. Goitein D, Feigin A, Segal-Lieberman G et al (2011) Laparoscopic sleeve gastrectomy as a revisional option after gastric band failure. Surg Endosc 25:2626–2630

    Article  PubMed  Google Scholar 

  27. Kehagias I, Karamanakos SN, Argentou M et al (2011) Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI < 50 kg/m2. Obes Surg 21:1650–1656

    Article  PubMed  Google Scholar 

  28. Kockerling F, Schug-Pass C (2009) Gastroscopically controlled laparoscopic sleeve gastrectomy. Obes Facts 2(Suppl 1):15–18

    Article  PubMed  Google Scholar 

  29. Lacy A, Ibarzabal A, Pando E et al (2010) Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech 20:351–356

    Article  PubMed  Google Scholar 

  30. Maher JW, Bakhos W, Nahmias N et al (2009) Drain amylase levels are an adjunct in detection of gastrojejunostomy leaks after Roux-en-Y gastric bypass. J Am Coll Surg 208:881–884 discussion 885–886

    Article  PubMed  Google Scholar 

  31. Marquez MF, Ayza MF, Lozano RB et al (2010) Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg 20:1306–1311

    Article  PubMed  Google Scholar 

  32. Martin-Malagon MDA, Rodriguez-Ballester MDL, Arteaga-Gonzalez MDI (2011) Total gastrectomy for failed treatment with endotherapy of chronic gastrocutaneous fistula after sleeve gastrectomy. Surg Obes Relat Dis 7(2):240–242

    Article  PubMed  Google Scholar 

  33. Mognol P, Chosidow D, Marmuse JP (2005) Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: initial results in 10 patients. Obes Surg 15:1030–1033

    Article  PubMed  Google Scholar 

  34. Moy J, Pomp A, Dakin G et al (2008) Laparoscopic sleeve gastrectomy for morbid obesity. Am J Surg 196:e56–e59

    Article  PubMed  Google Scholar 

  35. Nguyen NT, Nguyen XM, Dholakia C (2010) The use of endoscopic stent in management of leaks after sleeve gastrectomy. Obes Surg 20(9):1289–1292

    Article  PubMed  Google Scholar 

  36. Papavramidis TS, Kotzampassi K, Kotidis E et al (2008) Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch. J Gastroenterol Hepatol 23:1802–1805

    Article  PubMed  Google Scholar 

  37. 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 16:1323–1326

    Article  PubMed  Google Scholar 

  38. Rosenthal RJ (2012) International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 8:8–19

    Article  PubMed  Google Scholar 

  39. Sanchez-Santos R, Masdevall C, Baltasar A et al (2009) Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry. Obes Surg 19:1203–1210

    Article  PubMed  Google Scholar 

  40. Serra C, Baltasar A, Andreo L et al (2007) Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy. Obes Surg 17:866–872

    Article  PubMed  Google Scholar 

  41. Tan JT, Kariyawasam S, Wijeratne T et al (2010) Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg 20:403–409

    Article  PubMed  Google Scholar 

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Disclosures

Nasser Sakran, David Goitein, Asnat Raziel, Andrei Keidar, Nahum Beglaibter, Ronit Grinbaum, Ibrahim Matter, Ricardo Alfici, Ahmad Mahajna, Igor Waksman, Mordechai Shimonov, and Ahmad Assalia have no conflicts of interest or financial ties to disclose.

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Correspondence to Nasser Sakran.

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Nasser Sakran and David Goitein have equally contributed to this paper.

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Sakran, N., Goitein, D., Raziel, A. et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 27, 240–245 (2013). https://doi.org/10.1007/s00464-012-2426-x

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  • DOI: https://doi.org/10.1007/s00464-012-2426-x

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