Leak After Sleeve Gastrectomy: A Videoscopic Documentation on Occurrence, Diagnosis, and Treatment

Abstract

Introduction: Leak after a sleeve gastrectomy varies between 1.1% and 4.7% with a 7% mortality rate.1,2 This video of the primary operation shows a staple line failure coupled with problematic stitching, suggesting an overlooked micro-leak. Methods: In 1163 consecutive sleeve gastrectomies, two leaks (0.17%) occurred, and both were associated with technical failures. Our protocols/technique and changes during the Covid-19 pandemic were reported.3,4 In brief, the protocol includes staple-line reinforcement with full-thickness-continuous-suturing without imbrication, drainage, discharge on postoperative day three, and a selective leak test. The first leak occurred in a patient with a body mass index of 67 kg/m2 with an obstructed distal sleeve at the incisura. This was diagnosed on postoperative day nine and managed by emergency conversion to a gastric bypass. This approach avoided a stent.5 The second patient developed fever on postoperative day three which was attributed to pneumonia. An upper gastrointestinal (UGI) study and computed tomogram (CT) failed to identify a leak. There was no stenosis. A leak was diagnosed ultimately on postoperative day 12 on a repeat UGI study and confirmed with a CT scan. Results: Re-laparoscopy was performed for debridement, stenting, and drainage. A central catheter was inserted for total parenteral nutrition. Subsequent management required repeat hospital admissions, aspirations of abscesses/collections under radiologic guidance, and administration of antibiotics/antifungal agents. Subsequently, the stent was removed on day 54 with resolution of the metabolic syndrome and a 20 kg weight loss. Conclusions: Esophagogastric (EG)-junction encompasses the lower esophageal sphincter and the small “B” formations were unable to provide sufficient closure in this area. Moving the stapler off the EG-junction or using cartridges with larger/deeper “B” formations may have prevented this leak. Full-thickness-continuous-stitching might also have prevented the leak but failed because of technical reasons in this case. A leak test, if performed, may have identified the leak intraoperatively. Overall, leak presentation may be variable and management must be individualized. Leaks that are diagnosed a week after surgery are generally attributed to “non-technical” issues (i.e., ischemia). Our decade-long experience in 1163 consecutive patients contradicts this view and suggests that leaks occur because of technical errors and, therefore, may be preventable. If required, double cuffed stents which can be placed under laparo-endoscopic guidance seems to be a reasonable option provided that the distal cuff is neatly deployed in the duodenal bulb. Since the distal cuff is also fully covered, this must not occlude the pancreatic duct. Migration even a few cm distally will not be tolerable and requires stent re-positioning. No competing financial interests exist. Runtime of video: 9 mins 24 secsPatient Consent: Authors have received and archived patient consent for the video. All individuals appearing in the video also gave written consent to use their footage.