Further supporting LSG as a preferred procedure is the lower leak rates, the twofold lower complication rate, and a mortality rate that is half that of Roux–en–Y gastric bypass . When looking at only studies conducted in the US, the APM reinforcement method continues to have the lowest leak rate (0.39%) among the reinforcement methods evaluated (Table 4). APM absorbable polymer membrane, BPS bovine pericardial strips, N number of patients, NO-SLR no staple-line reinforcement, seal tissue sealant, suture oversewing alone
Associated Data
No major intraoperative complications were recorded and neither intraoperative nor perioperative deaths within 24 hours after surgery were noted. All procedures were performed laparoscopically with no conversion to open daman game app surgery. A 36-French bougie (12 mm) was positioned in the stomach, close to the lesser curvature, as a calibration for the gastric resection, starting about 5 cm laterally to the pylorus up to the angle of His. The greater omentum was dissected away from the greater gastric curvature with the harmonic scalpel (Ultracision® Ethicon).
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A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019. It is essential to keep in mind that the mortality from sleeve leaks is possible . Complying with every post-operative instruction, particularly the content, amount, and manner of eating, can also aid in preventing sleeve leakage. While staple line reinforcement, fibrin sealants, and bougie size are all potential strategies to decrease the leakage rate, further research is needed to determine their effectiveness 8,9. Inserting an additional nasogastric tube into the Roux limb can assist in keeping the anastomosis open while enabling enteral feeding, which can aid in a more rapid improvement of the patient’s condition . After an anastomosis is formed between the fistula orifice and the jejunum, in which a small opening has been created, the Roux limb can serve as a channel for saliva and food to exit, thereby improving sleeve leakage.
Figure 7.
For the purposes of this study, we analyzed patient data that underwent LSG at the General University Hospital of Patras for a span of 17 years—starting in January 2005 and ending in December 2022. Currently, there is an identifiable gap in the surgical literature, regarding several aspects of post-LSG leaks, evidenced by a lack of definitive guidelines for their management strategies. The American Society for Metabolic and Bariatric Surgery (ASMBS) has recognized the significant impact of LSG, and utilizing long-term outcome data from large studies, has officially classified it as a primary bariatric operation for the management of morbid obesity . More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Selected operative strategies can result in lower leak rates after sleeve gastrectomy.
1. Causes of Sleeve Leakage
One was diagnosed after routine radiographical upper GI series with no change in drain biochemistry (Type B leak) and the other had solely increased amylase drain levels with no radiographic evidence of a leak (Type A leak). Hemodynamic instability requiring aggressive resuscitation on presentation was found in only one (4.2%) patient of our cohort. Current consensus states that a 36 Fr size bougie is the most widely used 17,18,19,20, with multiple bougie sizes being reported as preferred in the literature. All procedures were performed by bariatric consultant surgeons with more than 10 years of bariatric surgery experience. In addition to SG, several other types of bariatric–metabolic procedures (including RYGB and one anastomosis gastric bypass) are performed at our institution.
Therefore, it is recommended to use general anesthesia to ensure stability during PTEG for patients with obesity . However, in patients with obesity, dilation of the RFB in the cervical esophagus and added pressure on the neck with an ultrasonic transducer can easily trigger a vomiting reflex. The PTEG was initially performed in malnourished patients who experienced difficulties with oral feeding under local anesthesia and intravenous sedation . Self-expandable removable stent treatment has a high success rate of up to 80% for leak closure. Additionally, achalasia balloon dilation involves passing a catheter through the stenosis along a guidewire under fluoroscopic guidance, which can be risky in cases of severe gastric tube tortuosity. It is worth attempting the endoscopic balloon dilation procedure a few more times, even if the first or second attempts are unsuccessful, as the third dilation may sometimes result in stenosis release .
All patients with diagnosis of a leak were initially discharged home in good clinical conditions and then returned to A&E because of the complication. Finally, there are studies demonstrating operative management can be pursued with conversion to Roux-en-Y gastric bypass or Roux-en-Y esophagojejunostomy as a last resort.14 However, conversion operations present a difficult challenge given the extent of disease and present the potential for their own known complications. If the patient fails to improve with these interventions or develops worsening clinical picture or fluid collection, operative washout and drainage with jejunostomy tube placement should be pursued.
Methods:
Prompt consideration should be given to draining the leakage sites. However, patients with obesity have thick abdominal walls and a clear image may not be produced, even with an undiluted contrast medium; therefore, care must be taken to avoid false negatives. Fluoroscopy with a water-soluble contrast agent can also be used to identify the leakage site.
- This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development.
- Two of these patients were managed laparoscopically while one required laparotomy due to small bowel serosal injury during washout.
- 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.
- The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS).
3. Statistical Analysis
Additionally, endoscopic stenting required a longer period until the confirmation of biochemical and clinical resolution of the staple line leak. Endoscopic stenting was used in 53.8% of our patients with a perfect success rate. Patients treated with endoluminal stents achieve high success rates of up to 100% in several studies 49,50,51,52,53, including our own.
Those who were more stable on presentation were initially treated with esophagogastroduodenoscopy (EGD) and stenting with possible percutaneous drainage if a drainable collection was present. Those who were septic were taken for diagnostic laparoscopy with washout and drainage. Within our practice, 1,116 laparoscopic sleeve gastrectomies were performed between January 1, 2010 and December 31, 2019. All surgeons performed air leak test with air insufflation and methylene blue dye. The rest of the staple line from the gastric body up to the angle of His was performed with Covidien Tristaple purple stapler loads. Leaks from other bariatric procedures such as Roux-en-Y gastric bypass procedures, laparoscopic gastric banding, or conversion of previous LSG to Roux-en-Y gastric bypass were excluded.
As a primary aim of our work, we set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. Patients that were treated for any postoperative complication other than leakage (e.g., staple line bleeding) were not included in the study. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. As APM and Suture were the two reinforcements with the lowest leak rates, this comparison warrants further study.
In our patient population, time to leak presentation varied from postoperative day five to day 111, with average presentation at 29.3 days. Variables retrospectively obtained from the electronic medical record included descriptive statistics of our patients, timing of leak presentation, modality of diagnosis, initial management, additional interventions, and time to leak resolution. This study aims to examine management of staple line leaks at a single institution and compare our findings to those in the literature. As mentioned earlier, most surgeons would agree on the initial treatment for sleeve leakage.
- Administration of broad-spectrum antibiotics for coverage of intra-abdominal infections, as well as nutrition and hydration support, are key in the conservative management of such patients 45,46,47,48.
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- The shape of the proximal part of the stent and its angle with respect to the stent body allowed complete coverage of the leak, thus promoting the healing process.
- To achieve successful leak closure, it is imperative to prevent disturbances to the distal passage beyond the leakage site.
- In addition, the indications and decisions for the various therapeutic interventions for PSLLs changed slightly or more over time.
Shortcomings of this approach include migration of covered stents that is reported in 17–58% of the patients, requiring repetition of the endoscopy procedure 54,55. It must be noted however, that endoscopic stenting required additional attempts in a few of our patients, and thus, resulted in an increased average hospitalization length. Administration of broad-spectrum antibiotics for coverage of intra-abdominal infections, as well as nutrition and hydration support, are key in the conservative management of such patients 45,46,47,48. When considering patients without such a catastrophic presentation, a variety of management options have been described in the literature. Treating the postoperative leaks after SG remains a field lacking a standard algorithm, despite many surgical teams having developed several individual ones.
Enteral nutrition has also been reported to accelerate leak healing. Therefore, suturing the gastric tube to the mesentery or abdominal wall during reoperation is advisable in preventing such complications . When a passage disturbance is caused by a stenosis or a twisting distal to the leak site, increased intragastric pressure can make it difficult for the leak site to heal. The timing of leakage and extent of abscess formation determine whether suturing is viable for closing the fistula. Laparoscopic drainage is frequently used because of its ability to facilitate concurrent washout and primary repair of the leak site .
