Surgical Endoscopy

, Volume 26, Issue 6, pp 1509–1515 | Cite as

Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients

  • Alexander R. Aurora
  • Leena Khaitan
  • Alan A. SaberEmail author



Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation.


An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were “sleeve gastrectomy” OR “gastric sleeve” AND “leak.” We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation.


The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m2] and 2.2% for BMI < 50 kg/m2. Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful.


Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI < 50 kg/m2) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge.


Sleeve gastrectomy Gastric sleeve Leak Bleeding Buttressing Bougie size 



Dr. Saber is a consultant for Covidian, Baxter, and King Pharmaceutical. Drs. Khaitan and Aurora have no conflicts of interest or financial ties to disclose.


  1. 1.
    Cottam D, Qureshi FG, Mattar SG, Sharma S, Holover S, Bonanomi G, Ramanathan R, Schauer P (2006) Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 20:859–863PubMedCrossRefGoogle Scholar
  2. 2.
    Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, Gfrerer L, Ludvik B, Zacherl J, Prager G (2010) Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin. Obes Surg 20:535–540PubMedCrossRefGoogle Scholar
  3. 3.
    Felberbauer FX, Langer F, Shakeri-Manesch S, Schmaldienst E, Kees M, Kriwanek S, Prager M, Prager G (2008) Laparoscopic sleeve gastrectomy as an isolated bariatric procedure: intermediate-term results from a large series in three Austrian centers. Obes Surg 18:814–818PubMedCrossRefGoogle Scholar
  4. 4.
    Srinivasa S, Hill LS, Sammour T, Hill AG, Babor R, Rahman H (2010) Early and mid-term outcomes of single-stage laparoscopic sleeve gastrectomy. Obes Surg 20:1484–1490PubMedCrossRefGoogle Scholar
  5. 5.
    Frezza EE, Reddy S, Gee LL, Wachtel MS (2009) Complications after sleeve gastrectomy for morbid obesity. Obes Surg 19:684–687PubMedCrossRefGoogle Scholar
  6. 6.
    Stroh C, Birk D, Flade-Kuthe R, Frenken M, Herbig B, Höhne S, Köhler H, Lange V, Ludwig K, Matkowitz R, Meyer G, Pick P, Horbach T, Krause S, Schäfer L, Schlensak M, Shang E, Sonnenberg T, Susewind M, Voigt H, Weiner R, Wolff S, Wolf AM, Schmidt U, Lippert H, Manger T; Bariatric Surgery Working Group (2009) Results of sleeve gastrectomy—data from a nationwide survey on bariatric surgery in Germany. Obes Surg 19:632–640Google Scholar
  7. 7.
    Sánchez-Santos R, Masdevall C, Baltasar A, Martínez-Blázquez C, Ruiz García, de Gordejuela A, Ponsi E, Sánchez-Pernaute A, Vesperinas G, Del Castillo D, Bombuy E, Durán-Escribano C, Ortega L, Ruiz de Adana JC, Baltar J, Maruri I, García-Blázquez E, Torres A (2009) Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry. Obes Surg 19:1203–1210PubMedCrossRefGoogle Scholar
  8. 8.
    Bellanger DE, Greenway FL (2011) Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 21:146–150PubMedCrossRefGoogle Scholar
  9. 9.
    Chowbey PK, Dhawan K, Khullar R, Sharma A, Soni V, Baijal M, Mittal T (2010) Laparoscopic sleeve gastrectomy: an Indian experience - surgical technique and early results. Obes Surg 20:1340–1347PubMedCrossRefGoogle Scholar
  10. 10.
    Lee CM, Cirangle PT, Jossart GH (2007) Vertical gastrectomy for morbid obesity in 216 patients: report of 2-year results. Surg Endosc 21:1810–1816PubMedCrossRefGoogle Scholar
  11. 11.
    Weiner RA, Weiner S, Pomhoff I, Jacobi C, Makarewicz W, Weigand G (2007) Laparoscopic sleeve gastrectomy: influence of sleeve size and resected gastric volume. Obes Surg 17:1297–1305PubMedCrossRefGoogle Scholar
  12. 12.
    Johnston D, Dachtler J, Sue-Ling HM, King RF, Martin G (2003) The Magenstrasse and Mill operation for morbid obesity. Obes Surg 13:10–16PubMedCrossRefGoogle Scholar
  13. 13.
    Dapri G, Cadière GB, Himpens J (2010) Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg 20:462–467PubMedCrossRefGoogle Scholar
  14. 14.
    Elariny H, González H, Wang B (2005) Tissue thickness of human stomach measured on excised gastric specimens from obese patients. Surg Tech Int 14:119–124Google Scholar
  15. 15.
    Oshiro T, Kasama K, Umezawa A, Kanehira E, Kurokawa Y (2010) Successful management of refractory staple line leakage at the esophagogastric junction after a sleeve gastrectomy using the HANAROSTENT. Obes Surg 20:530–534PubMedCrossRefGoogle Scholar
  16. 16.
    Fuks D, Verhaeghe P, Brehant O, Sabbagh C, Dumont F, Riboulot M, Delcenserie R, Regimbeau JM (2009) Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery 145:106–113PubMedCrossRefGoogle Scholar
  17. 17.
    Moon Han S, Kim WW, Oh JH (2005) Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 15:1469–1475PubMedCrossRefGoogle Scholar
  18. 18.
    Roa PE, Kaidar-Person O, Pinto D, Cho M, Szomstein S, Rosenthal RJ (2006) Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short term outcome. Obes Surg 16:1323–1326PubMedCrossRefGoogle Scholar
  19. 19.
    Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ (2008) Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 4:33–38PubMedCrossRefGoogle Scholar
  20. 20.
    Nocca D, Krawczykowsky D, Bomans B, Noël P, Picot MC, Blanc PM, de Hons C, Millat B, Gagner M, Monnier L, Fabre JM (2008) A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Obes Surg 18:560–565PubMedCrossRefGoogle Scholar
  21. 21.
    Kasalicky M, Michalsky D, Housova J, Haluzik M, Housa D, Haluzikova D, Fried M (2008) Laparoscopic sleeve gastrectomy without an over-sewing of the staple line. Obes Surg 18:1257–1262PubMedCrossRefGoogle Scholar
  22. 22.
    Mui WL, Ng EK, Tsung BY, Lam CC, Yung MY (2008) Laparoscopic sleeve gastrectomy in ethnic obese Chinese. Obes Surg 18:1571–1574PubMedCrossRefGoogle Scholar
  23. 23.
    Rubin M, Yehoshua RT, Stein M, Lederfein D, Fichman S, Bernstine H, Eidelman LA (2008) Laparoscopic sleeve gastrectomy with minimal morbidity. Early results in 120 morbidly obese patients. Obes Surg 18:1567–1570PubMedCrossRefGoogle Scholar
  24. 24.
    Skrekas G, Lapatsanis D, Stafyla V, Papalambros A (2008) One year after laparoscopic “tight” sleeve gastrectomy: technique and outcome. Obes Surg 18:810–813PubMedCrossRefGoogle Scholar
  25. 25.
    Burgos AM, Braghetto I, Csendes A, Maluenda F, Korn O, Yarmuch J, Gutierrez L (2009) Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg 19:1672–1677PubMedCrossRefGoogle Scholar
  26. 26.
    Goitein D, Goitein O, Feigin A, Zippel D, Papa M (2009) Sleeve gastrectomy: radiologic patterns after surgery. Surg Endosc 23:1559–1563PubMedCrossRefGoogle Scholar
  27. 27.
    Kakoulidis TP, Karringer A, Gloaguen T, Arvidsson D (2009) Initial results with sleeve gastrectomy for patients with class I obesity (BMI 30–35 kg/m2. Surg Obes Relat Dis 5:425–428PubMedCrossRefGoogle Scholar
  28. 28.
    Menenakos E, Stamou KM, Albanopoulos K, Papailiou J, Theodorou D, Leandros E (2010) Laparoscopic sleeve gastrectomy performed with intent to treat morbid obesity: a prospective single-center study of 261 patients with a median follow-up of 1 year. Obes Surg 20:276–282PubMedCrossRefGoogle Scholar
  29. 29.
    Armostrong J, O’Malley SP (2010) Outcomes of sleeve gastrectomy for morbid obesity: a safe and effective procedure. Int J Surg 8:69–71CrossRefGoogle Scholar
  30. 30.
    Csendes A, Braghetto I, León P, Burgos AM (2010) Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg 14:1343–1348PubMedCrossRefGoogle Scholar
  31. 31.
    Lacy A, Ibarzabal A, Pando E, Adelsdorfer C, Delitala A, Corcelles R, Delgado S, Vidal J (2010) Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech 20:351–356PubMedCrossRefGoogle Scholar
  32. 32.
    Ser KH, Lee WJ, Lee YC, Chen JC, Su YH, Chen SC (2010) Experience in laparoscopic sleeve gastrectomy for morbidly obese Taiwanese: staple-line reinforcement is important for preventing leakage. Surg Endosc 24:2253–2259PubMedCrossRefGoogle Scholar
  33. 33.
    Casella G, Soricelli E, Rizzello M, Trentino P, Fiocca F, Fantini A, Salvatori FM, Basso N (2009) Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 19:821–826PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Alexander R. Aurora
    • 1
  • Leena Khaitan
    • 1
  • Alan A. Saber
    • 1
    Email author
  1. 1.Department of SurgeryUniversity Hospitals Case Medical CenterClevelandUSA

Personalised recommendations