Advertisement

Surgical Endoscopy

, Volume 27, Issue 1, pp 240–245 | Cite as

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

  • Nasser Sakran
  • David Goitein
  • Asnat Raziel
  • Andrei Keidar
  • Nahum Beglaibter
  • Ronit Grinbaum
  • Ibrahim Matter
  • Ricardo Alfici
  • Ahmad Mahajna
  • Igor Waksman
  • Mordechai Shimonov
  • Ahmad Assalia
Article

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.

Keywords

Gastric leak Laparoscopic sleeve gastrectomy Morbid obesity Morbidity Mortality 

Notes

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.

References

  1. 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 19:544–548CrossRefPubMedGoogle Scholar
  2. 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 22:97–104CrossRefPubMedGoogle Scholar
  3. 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):1509–1515CrossRefPubMedGoogle Scholar
  4. 4.
    Baltasar A, Serra C, Perez N et al (2005) Laparoscopic sleeve gastrectomy: a multipurpose bariatric operation. Obes Surg 15:1124–1128CrossRefPubMedGoogle Scholar
  5. 5.
    Baltasar A, Serra C, Perez N et al (2006) Re-sleeve gastrectomy. Obes Surg 16:1535–1538CrossRefPubMedGoogle Scholar
  6. 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 17:1408–1410CrossRefPubMedGoogle Scholar
  7. 7.
    Bellanger DE, Greenway FL (2011) Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 21:146–150CrossRefPubMedGoogle Scholar
  8. 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 72:862–864PubMedGoogle Scholar
  9. 9.
    Burgos AM, Braghetto I, Csendes A et al (2009) Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg 19:1672–1677CrossRefPubMedGoogle Scholar
  10. 10.
    Casella G, Soricelli E, Rizzello M et al (2009) Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 19:821–826CrossRefPubMedGoogle Scholar
  11. 11.
    Clinical Issues Committee of American Society for Metabolic and Bariatric Surgery (2007) Sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis 3:573–576CrossRefGoogle Scholar
  12. 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–E72CrossRefPubMedGoogle Scholar
  13. 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 20:859–863CrossRefPubMedGoogle Scholar
  14. 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 20:519–522CrossRefPubMedGoogle Scholar
  15. 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):1343–1348CrossRefPubMedGoogle Scholar
  16. 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 21:2268–2271CrossRefPubMedGoogle Scholar
  17. 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 5:72–76CrossRefPubMedGoogle Scholar
  18. 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 20:462–467CrossRefPubMedGoogle Scholar
  19. 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 25:88–97CrossRefPubMedGoogle Scholar
  20. 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 18:487–496CrossRefPubMedGoogle Scholar
  21. 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 19:645–649CrossRefPubMedGoogle Scholar
  22. 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 6:146–151CrossRefPubMedGoogle Scholar
  23. 23.
    Gagner M (2010) Leaks after sleeve gastrectomy are associated with smaller bougies: prevention and treatment strategies. Surg Laparosc Endosc Percutan Tech 20:166–169CrossRefPubMedGoogle Scholar
  24. 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 5:476–485CrossRefPubMedGoogle Scholar
  25. 25.
    Goitein D, Goitein O, Feigin A et al (2009) Sleeve gastrectomy: radiologic patterns after surgery. Surg Endosc 23:1559–1563CrossRefPubMedGoogle Scholar
  26. 26.
    Goitein D, Feigin A, Segal-Lieberman G et al (2011) Laparoscopic sleeve gastrectomy as a revisional option after gastric band failure. Surg Endosc 25:2626–2630CrossRefPubMedGoogle Scholar
  27. 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 21:1650–1656CrossRefPubMedGoogle Scholar
  28. 28.
    Kockerling F, Schug-Pass C (2009) Gastroscopically controlled laparoscopic sleeve gastrectomy. Obes Facts 2(Suppl 1):15–18CrossRefPubMedGoogle Scholar
  29. 29.
    Lacy A, Ibarzabal A, Pando E et al (2010) Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech 20:351–356CrossRefPubMedGoogle Scholar
  30. 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 885–886CrossRefPubMedGoogle Scholar
  31. 31.
    Marquez MF, Ayza MF, Lozano RB et al (2010) Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg 20:1306–1311CrossRefPubMedGoogle Scholar
  32. 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):240–242CrossRefPubMedGoogle Scholar
  33. 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 15:1030–1033CrossRefPubMedGoogle Scholar
  34. 34.
    Moy J, Pomp A, Dakin G et al (2008) Laparoscopic sleeve gastrectomy for morbid obesity. Am J Surg 196:e56–e59CrossRefPubMedGoogle Scholar
  35. 35.
    Nguyen NT, Nguyen XM, Dholakia C (2010) The use of endoscopic stent in management of leaks after sleeve gastrectomy. Obes Surg 20(9):1289–1292CrossRefPubMedGoogle Scholar
  36. 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 23:1802–1805CrossRefPubMedGoogle Scholar
  37. 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 16:1323–1326CrossRefPubMedGoogle Scholar
  38. 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 8:8–19CrossRefPubMedGoogle Scholar
  39. 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 19:1203–1210CrossRefPubMedGoogle Scholar
  40. 40.
    Serra C, Baltasar A, Andreo L et al (2007) Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy. Obes Surg 17:866–872CrossRefPubMedGoogle Scholar
  41. 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 20:403–409CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Nasser Sakran
    • 1
    • 9
  • David Goitein
    • 2
    • 10
  • Asnat Raziel
    • 3
  • Andrei Keidar
    • 4
  • Nahum Beglaibter
    • 4
  • Ronit Grinbaum
    • 4
  • Ibrahim Matter
    • 5
    • 9
  • Ricardo Alfici
    • 1
    • 9
  • Ahmad Mahajna
    • 6
    • 9
  • Igor Waksman
    • 7
  • Mordechai Shimonov
    • 8
    • 10
  • Ahmad Assalia
    • 6
    • 9
  1. 1.Department of SurgeryHillel Yaffe Medical CenterHaderaIsrael
  2. 2.Chaim Sheba Medical CenterTel HashomerIsrael
  3. 3.Assia Medical GroupAssuta HospitalTel AvivIsrael
  4. 4.Hadassah-Hebrew University Medical CenterJerusalemIsrael
  5. 5.Bnai Zion Medical CenterHaifaIsrael
  6. 6.Rambam Health Care CampusHaifaIsrael
  7. 7.Ziv Medical CenterZefatIsrael
  8. 8.Wolfson Medical CenterHolonIsrael
  9. 9.Ruth and Bruce Rappaport Faculty of MedicineTechnion Israel Institute of TechnologyHaifaIsrael
  10. 10.Sackler School of MedicineTel Aviv UniversityTel AvivIsrael

Personalised recommendations