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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 4  |  Page : 425-432

Dilemma with leakage after sleeve gastrectomy


Lecturers of General Surgery, Department of General Surgery Al-Azhar University, Cairo, Egypt

Date of Submission04-Jan-2019
Date of Acceptance20-Mar-2019
Date of Web Publication23-Apr-2019

Correspondence Address:
Mohammed Abbas
Mehallah Kobra Gharbiah Governorat

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_2_19

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  Abstract 


Objective The aim of this study was to evaluate methods of diagnosis and management of leakage after sleeve gastrectomy to decrease morbidity and mortality of this complication.
Background Leakage is the commonest and most feared early complication in bariatric procedures. Leakage can occur from any site of staple line. Incidence of leakage after sleeve gastrectomy is in the range of 1–3%. Risk factors for leaks and complications were increasing weight, male sex, multiple comorbidities, previous abdominal procedures, or revisional surgery. Tachycardia with a heart rate in excess of 120 beats per minute was a good indicator of leakage.
Patients and methods The study was conducted on 12 cases that had leakage after sleeve gastrectomy, where four cases were diagnosed early and were managed by re-exploration and repair of the site of leakage with feeding jejunostomy and eight cases were diagnosed late and managed as follows: five cases by gastric stent and pigtail for drainage of collection, two cases by exploration, and one case by pigtail insertion and conservative treatment.
Results In this study, four cases experienced mortality owing to delay in diagnosis and septicemia. Two cases develop gastropleural fistula. There was long hospital stay. Two cases developed incisional hernia, and one case developed deep venous thrombosis (DVT).
Conclusion Management of leakage in bariatric procedures requires early diagnosis and precise decision making tailored according to every case.

Keywords: gastrectomy, leakage, obesity, sleeve, stent


How to cite this article:
Abbas M, Seleem A. Dilemma with leakage after sleeve gastrectomy. Al-Azhar Assiut Med J 2018;16:425-32

How to cite this URL:
Abbas M, Seleem A. Dilemma with leakage after sleeve gastrectomy. Al-Azhar Assiut Med J [serial online] 2018 [cited 2019 Oct 15];16:425-32. Available from: http://www.azmj.eg.net/text.asp?2018/16/4/425/256751




  Introduction Top


One of the most significant changes in bariatric surgery over the past decade is the growing popularity of the laparoscopic sleeve gasterectomy (LSG). LSG involves a stapled vertical transection of the stomach and creation of a tubular alimentary channel along the stomach’s lesser curvature, calibrated along an orogastric bougie [1]. The most common complications documented by surgeons experienced in LSG include leak, hemorrhage, stenosis, spleen/liver injury, portal vein thrombosis, and reflux [2]. Postsleeve gastrectomy leaks and fistulas are reported to occur in 1–3% of patients. The difference between leaks and fistulas is the formation of an abnormal connection between two epithelialized surfaces, which occurs with the fistulas. The majority of these leaks (>90%) occur in the proximal staple line as a result of staple-line height mismatch, ischemia, and unfavorable pressure gradients secondary to distal intraluminal narrowing of the sleeve [3]. The mortality rate from leaks after LSG is 0.11% [4]. The vast majority of leaks (75–89%) occur proximally, near the gastroesophageal junction [5]. Leaks present at a mean of 7 days postoperatively but can present as late as 120 days postoperatively [3]. Most leaks present after patients are discharged home from the hospital; therefore, close follow-up in the immediate postoperative period is critical after LSG. Rosenthal and Panel [6] proposed a classification system for leak after LSG based on timing: acute leak (within 7 days postoperatively), early leak (within 1–5 weeks postoperatively), late leak (>6 weeks postoperatively), and chronic leak (after 12 weeks). Staple-line leak after LSG can present with many clinical scenarios, ranging from a stable patient with mild abdominal pain to a patient with manifestations of systemic inflammatory response syndrome to a patient with sepsis and multiorgan failure. Abdominal computed tomography (CT) scan with oral and intravenous contrast is the diagnostic study of choice for most patients suspected of having leak. Technical aspects of LSG, including bougie size used to calibrate the sleeve, distance from the pylorus where the stapling begins, height of stapler used to transect the stomach, and the role of buttressing material on the staple line, may affect leak rate. Debate exists whether the creation of tighter (i.e. smaller) sleeves results in higher leak rate [7]. Treatment options depend on the clinical scenario and range from intravenous antibiotics and nutritional support to interventions to surgical interventions [8].

The purpose of this study was to evaluate methods of diagnosis and management of leakage after sleeve gastrectomy to decrease morbidity and mortality of this complication.


  Patients and methods Top


The study was done in our Al-Azhar University Hospitals from January 2015 to March 2017. It was conducted on cases diagnosed with leakage after LSG, how they were managed, and mortality rate in these cases. Moreover, patients referred to our institution with gastric leak after LSG were also included.

Inclusion criteria

All patients with laparoscopic sleeve gastrectomy complicated with leakage, as well as patients with open sleeve gastrectomy done by either stapler or hand sewn were included.

Exclusion criteria

Patients with leakage after other types of bariatric sleeve gastrectomy rather than sleeve were excluded.

Patients with chronic leakage

The study was conducted on 12 cases that had leakage after sleeve gastrectomy. Each case underwent history taking preoperatively regarding weight, height, and BMI; history taking regarding diet regimen, whether sweet eater or bulky eater; history of associated comorbidities such as diabetes, hypertension, hyperlipidemia, and cardiac or respiratory problem; history taking regarding operative details such as its date, time of operation, type of operation, complication intraoperatively, time of discharge from hospital, when to do gastrografin radiograph, and when to start oral feeding; history of abdominal pain, fever, palpitation, and dyspnea; and history of medications (antibiotic, antipyretics, analgesic, and anticoagulants).

Preoperative and postoperative complaints either from abdominal pain, left hypochondrial pain, or manifestation of sepsis were also recorded.

Clinical examination included the following:

General examination, including vital data (pulse, temperature, blood pressure, and respiratory rate).

General condition of the patients (manifestation of toxicity, sepsis, or shock).

Local examination, which really is not dependable in obese patients (tenderness, rigidity of the abdomen, or rebound tenderness).

Examination of wound especially in open cases (discharge pus, gapped wound, or burst abdomen).

Drain: the amount of collected fluid and its characteristic.

Investigation including laboratory [complete blood count (CBC), liver function test, kidney function test, coagulation profile, blood sugar test, and arterial blood gases] and radiological investigation (abdominopelvic ultrasound, chest radiograph, gastrografin study, and the most important one is CT abdomen and pelvis with oral and intravenous contrast).

Based on clinical presentation, gastric leaks are classified as follows:
  1. Type I (subclinical): presence of leakage without early septic complications corresponding to drainage through a fistulous track and/or without generalized dissemination to the pleural or abdominal cavity with or without the appearance of contrast medium in any of the abdominal drains.
  2. Type II (clinical): presence of leakage with early septic complications corresponding to drainage by an irregular pathway (no well-formed fistulous tract) and a more generalized dissemination into the pleural or abdominal cavity with or without appearance of contrast medium in any of the abdominal drains.


Based on the time when the leaks presented, they are classified as follows:
  1. Early (leaks appearing 1–3 days after surgery).
  2. Intermediate (leaks appearing 4–7 days after surgery).
  3. Late (leaks appearing ≥8 days after surgery).


Patient details

First case

A 35-year-old male patient with BMI of 50 presented with leakage after LSG. Gastrografin and CT abdomen and pelvis done 1 week after surgery revealed leakage at gastroesophageal junction. The patient presented with early signs of sepsis. We inserted mega stent and pigtail drainage of intra-abdominal collection with good improvement ([Figure 1]).
Figure 1 Endoscopic mega stent.

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Second case

A 25-year-old female patient presented with bleeding on second day after surgery. We did open exploration and there was bleeding in greater omentum and at short gastric blood vessels. There was good hemostasis by ligature and secondary suture. Six days later, the patient presented with signs of sepsis and unstable condition. On open exploration, there was leakage at gastroesophageal junction. Roux-en Y gastro-jejunostomy was done. Later on in the follow-up, the patient enter in sepsis and died.

Third case

A 38-year-old female patient presented with signs and symptoms of gastric leak 2 weeks postoperatively. CT abdomen was done, and there was collection at left hypochondrium and left pleural large abscess. We inserted a mega stent and chest tube ([Figure 2]).
Figure 2 Computed tomography finding of left pleural abscess.

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Fourth case

A 42-year-old female patient presented with fever and abdominal pain 6 days postoperatively with pus discharge in drain. Gastrografin was done, and there was leakage at gastroesophageal junction. Upper gastrointestinal tract endoscopy detected the site of fistula. We inserted a mega stent for 4 weeks ([Figure 3]).
Figure 3 Endoscopic cannulation of the fistula.

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Fifth case

A 19-year-old male patient presented with post-LSG fever and abdominal pain on fourth day. Ultrasonography result was normal, and on gastrografin, there is no definitive site of leakage. This was diagnosed as subclinical leakage, and conservative treatment was done.

Sixth case

A 28-year-old male patient underwent open sleeve gastrectomy outside our hospital. On 20 days postoperatively, the patient developed symptoms and signs of leakage. CT abdomen and pelvis examination was done, and there was left subphrenic collection. Pigtail was inserted to drain this abscess, but it converted to generalized peritonitis from leakage around pigtail into peritoneum. Open exploration was done, which revealed there is pus in abdomen from left subphrenic collection. There is no definitive site of leakage. A drain was inserted and closed in the patient. Two weeks later, the patient developed same symptoms. CT was done, and there was another left subphrenic collection ([Figure 4]).
Figure 4 Left subphrenic abscess.

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Open exploration revealed that there is large left subphrenic collection. Drainage was done, and at same time, upper endoscopy was done. There is no remarkable site of leakage, but we inserted a mega stent and the patient passed well. The stent was removed 2 months later, but the patient developed a large incisional hernia.

Seventh case

A 46-year-old male patient underwent open sleeve gastrectomy and presented with symptoms of leakage 5 days postoperatively. CT shows there is leakage at gastroesophageal junction. A mega stent was inserted and left for ∼8 weeks. There was improvement of general condition, but the patient began complaining of dysphagia. We did upper gastrointestinal tract endoscope, and there was severe narrowing just above the stent, which could not be passed by guide wire. Patient underwent another open surgery and removal of stent. In follow-up, the patient entered into fistula and sepsis and died ([Figure 5]).
Figure 5 Stent after removal.

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Eighth case

A 50-year-old male patient presented with pleural fistula 10 days after surgery. Gastrografin showed fistula at lower esophagus connected to left pleura. A mega stent and chest tube insertion was done. There was good improvement in condition ([Figure 6]).
Figure 6 Leakage to left pleura.

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Ninth case

A 33-year-old female patient presented with leakage after open sleeve gastrectomy as redo after butterfly gastroplasty. On the 7th day, she presented with leakage, which was diagnosed by gastrografin. We did upper endoscopy and inserted clips on the site of fistula but could not close the site of leakage properly. We inserted a mega stent so that the amount of pus discharged from the wound would decrease, but it continued for more than 5 weeks. On repeated upper endoscopy, there was migration of stent. Resetting of the stent was done into its position again. But the wound converted to chronic fistula ([Figure 7]).
Figure 7 Endoscopic finding of fistula.

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Tenth case

A 25-year-old female patient with BMI of 65 presented with leakage after sleeve gastrectomy. CT shows that there is leakage at gastroesophageal junction. Insertion of a mega stent was done then removed after six weeks. The patient develop chest pain 10 days later. CT chest was done, which showed that there was right hydro-pneumothorax. Endoscopy showed perforation at upper esophagus, which was managed by chest tube for drainage and jejunostomy tube for feeding. A month later, the patient showed improvement. A dye study revealed normal results. One month later, the patient developed persistent vomiting. Upper endoscopy showed stricture between upper two-thirds and lower one-third of esophagus. Dilatation was done. Patient developed severe malnutrition.

Eleventh case

A 37-year-old male patient presented with leakage at lower one-third of esophagus 6 weeks postoperatively, which was managed by clips [Table 1] and [Table 2] and [Figure 8].
Table 1 Demographic data of the patients

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Table 2 Management of patients and outcome

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Figure 8 Endoscopic clip.

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Twelfth case

A 35-year-old female patient presented with leakage after LSG 4 weeks later. So a dye study was done and showed fistula at cardiac site. A mega stent was inserted [Figure 9].
Figure 9 Radiograph of stent with gastrografin.

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  Discussion Top


LSG is one of the most popular restrictive bariatric procedure done either as standalone operation or as the first stage of the laparoscopic duodenal switch. In this study, we analyzed cases presenting with gastric leak after LSG performed at our department and also referred cases over a 3-year period from 2015 to 2018. So we cannot decide the incidence of gastric leak, but recent reports documented an average incidence of 1.1% for post-LSG leaks [9]. Others reported leakage rates ranging from 0 to 3.9% [10].

Picture of the patients at the time of presentation

Staple-line leak after LSG can present with many clinical scenarios, ranging from a stable patient with mild abdominal pain to a patient with manifestations of systemic inflammatory response syndrome to a patient with sepsis and multiorgan failure. A high index of suspicion is important, as early intervention is the key to successful management of these patients [11].

In this study, leakage after surgery presented at fourth day to sixth weeks postoperatively but mostly at the end of first week. Moreover, Sakran stated that leaks present at a mean of 7 days postoperatively, but can present as late as 120 days postoperatively [3]. Most leaks present after patients are discharged home from the hospital; therefore, close follow-up in the immediate postoperative period is critical after surgery.

Diagnostic study

We have cases with normal study results on gastrografin but showed evidence of leak in CT with contrast. Mittermair et al. [12] also found that the choice of diagnostic study for most patients suspected of having leak is abdominal CT scan with oral and intravenous contrast. Findings in the CT may range from blips of extra luminal air to frank contrast extravasation. Barium gastrografin may also be used to diagnose leak; however, it may be normal despite the presence of leak as it cannot detect minor leaks. The value of immediate postoperative upper gastrointestinal studies has been debated as leaks often present after patients have been discharged from the hospital.

Different management strategies of leak after LSG

Different models of management were offered according to patient status and presence of sepsis or not, ranging from conservative treatment, endoscopy stenting, clipping of fistula, to surgical intervention. Moreover, de Aretxabala et al. [8] found that treatment options depend on the clinical scenario and range from intravenous antibiotics and nutritional support to endoscopic interventions, including stenting to surgical interventions such as gastrectomy with Roux-en Y esophagojejunostomy or fistula-jejunostomy. Sepsis control and nutritional support are cornerstones of management, but specific treatments should be based on a patient’s clinical presentation and timing of the leak.

Most of our cases were managed by endoscopic stent, and Casella et al. [13] evidenced the evolution of endoscopic stents to treat leaks, where most leaks may be treated without definitive surgery.

Conservative treatment

It included close follow-up of patients, intravenous antibiotic, drainage of abscess, and maintaining good nutrition by parenteral alimentation.

Endoscopic intervention

Lorenzo et al. [14] reported their endoscopic management of postsleeve gastrectomy leaks in a large cohort at a tertiary referral center in France from 2007 to 2015. The authors report their experience before and after 2013, when management switched from ‘closure’ techniques to endoscopic internal drainage. An esophageal covered flexible self-expanding metallic stent (mega stent) designed especially for sleeve leaks can be used to exclude the site of leak if it is small and present just beyond esophagogastric junction. The stent provides a temporary seal of the leak while also allowing oral intake during the process of healing. Stents may also aid in the correction of the sleeve axis in cases of gastric torsion or twist [15]. Another major advantage is that feeds can be continued orally and need not be interrupted. Complications included stent migration, hematemesis, erosion, and granulation over growth, which lead in obstruction.

Other endoscopic intervention include clips. which achieved success in one case (case 11), as the perforation was closed completely, and another one failed (case 12), as the size of perforation was large. Dakwar et al. [16] have reported successful management of LSG leak with a 10-mm over-the-scope metallic clip.

Surgical interventions

Surgical management of septic peritonitis from leakage as in case 6 and to remove of stent as in case 7 but best results in sepsis control could be achieved by early intervention either by open or laparoscopic surgery. Although in late leakage, it is advised to wait for at least 12 weeks before definitive surgical management to avoid dense adhesions [2], Moszkowicz et al. [17] stated that surgery for definitive treatment of LSG leak can have substantial morbidity, as could be seen in this study with two cases of mortality.


  Conclusion Top


A high index of suspicion and CT scan constitute the mainstay for the diagnosis of sleeve leaks. Decision of management should be individualized according to clinical presentation. Early intervention is the key to successful management of these patients. Less invasive is better results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 2013; 216:252–257.  Back to cited text no. 1
    
2.
Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg 2013; 23:2013–2017.  Back to cited text no. 2
    
3.
Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis 2016; 12:750–756.  Back to cited text no. 3
    
4.
Rebibo L, Dhahri A, Chati R, Cosse C, Huet E, Regimbeau JM. Effectiveness of fibrin sealant application on the development of staple line complications after sleeve gastrectomy: a prospective randomized trial. Ann Surg 2018; 268:762–768.  Back to cited text no. 4
    
5.
Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012; 26:1509–1515.  Back to cited text no. 5
    
6.
Rosenthal RJ, Panel IS. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 2012; 8:8–19.  Back to cited text no. 6
    
7.
Gagner M. Leaks after sleeve gastrectomy are associated with smaller bougies: prevention and treatment strategies. Surg Laparosc Endosc Percutan Tech 2010; 20:166–169.  Back to cited text no. 7
    
8.
De Aretxabala X, Leon J, Wiedmaier G, Turu I, Ovalle C, Maluenda F et al. Gastric leak after sleeve gastrectomy: analysis of its management. Obes Surg 2011; 21:1232–1237.  Back to cited text no. 8
    
9.
Strain GW, Saif T, Gagner M, Rossidis M, Dakin G, Pomp A. Cross-sectional review of effects of laparoscopic sleeve gastrectomy at 1, 3, and 5 years. Surg Obes Relat Dis 2011; 7:714–719.  Back to cited text no. 9
    
10.
Santoro S, Milleo FQ, Malzoni CE, Klajner S, Borges PC, Santo MA et al. Enterohormonal changes after digestive adaptation: five-year results of a surgical proposal to treat obesity and associated diseases. Obes Surg 2008; 18:17–26.  Back to cited text no. 10
    
11.
Dallal RM, Bailey L, Nahmias N. Back to basics-clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary. Surg Endosc 2007; 21:2268–2271.  Back to cited text no. 11
    
12.
Mittermair R, Sucher R, Perathoner A, Wykypiel H. Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary. Am J Surg 2014; 207:897–901.  Back to cited text no. 12
    
13.
Casella G, Soricelli E, Rizzello M, Trentino P, Fiocca F, Fantini A et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 2017; 19:821–826.  Back to cited text no. 13
    
14.
Lorenzo D, Guilbaud T, Gonzalez JM, Benezech A, Dutour A, Boullu S et al. Endoscopic treatment of fistulas after sleeve gastrectomy: a comparison of internal drainage versus closure. Gastrointest Endosc 2018; 87:429–437.  Back to cited text no. 14
    
15.
Rossetti G, Fei L, Docimo L, Del Genio G, Micanti F, Belfiore A et al. Is nasogastric decompression useful in prevention of leaks after laparoscopic sleeve gastrectomy? A randomized trial. J Invest Surg 2014; 27:234–239.  Back to cited text no. 15
    
16.
Dakwar A, Assalia A, Khamaysi I, Kluger Y, Mahajna A. Late complication of laparoscopic sleeve gastrectomy. Case Rep Gastrointest Med 2013; 2013:136153.  Back to cited text no. 16
    
17.
Moszkowicz D, Arienzo R, Khettab I, Rahmi G, Zinzindohoué F, Berger A, Chevallier JM. Sleeve gastrectomy severe complications: is it always a reasonable surgical option?. Obes Surg 2013; 23: 676–686.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2]



 

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