1. Unusual leak in sleeve gastrectomy
Dr.Mohammad Hayssam ElFawal MD.FACS Dr.Houssam Abtar. Chief Resident MEMA 11th May 2013

2. MORBID OBESITY
30 years old female , morbidly obese with BMI 42.5 (Wt 97kg, Ht 151cm) presented to MGH for elective laparoscopic sleeve gastrectomy .
She is known to have DM II(on glucophage)

3. MORBID OBESITY
Patient underwent uneventful laparoscopic sleeve gastrectomy.
Bleeding from staple line
How would u control your staple line bleed?
Day 1 post op she had an upper GI series performed and showed no leakage or obstruction.

4. Up on arrival

5. UGI day one? Is it evidence based or a surgeon preference (I want to sleep!!!!)

6. MORBID OBESITY Patient discharged home on Day 1 on liquid diet.
Represented 2 days later with Lt upper quadrant . No nausea or vomiting.
No Drains
Who is draining routinely his sleeves?
P/E: periumbilical and LUQ tenderness no rebound or rigidity
T: HR:110

7. Labs U/A Hct Hb seg WBC Nl 39 13 93% 12000 CRP INR SGPT GGT Alk Ph
lipase
amylase
7.8
1.2 35
211
143 40 48

9. CXR

10. UPPER GI SERIES

11. UPPER GI SERIES
The Extravasation of contrast material through the wall of the gastric sleeve, free intra-
abdominal contrast material, and free intra-abdominal gas, left sub diaphragmatic
free pocket of air

12. UPPER GI SERIES
NORMAL
LEAKAGE

13. EXPLORATORY LAPAROSCOPY
Laparoscopic exploration showed pus in the peritoneal cavity (LUQ) and methylene blue test showed leak approximately 10 cm from the pylorus at the staple line.

15. AFTER REPAIR

16. Patient did well post revision and discharged home on day 8 post op on clear fluid diet

17. UGI Series
No consensus exists regarding the timing of this test; some authors perform it 1 day after the procedure, whereas others, routinely perform it 3 days after the procedure. The fact of the test being negative 3 days after surgery could give rise to a false sense of security since most leaks appear after the third day.
A lot of centers stopped doing UGI series as a routine in the postoperative period.
Obes Surg Jul;22(7): Brockmeyer JR et al.
Upper gastrointestinal swallow study following bariatric surgery: institutional
Dwight David Eisenhower Army Medical Center, 300 Hospital Rd, Fort Gordon, GA 30905, USA. review and review of the literature.

18. Drain versus no drain 353 sleeve Patients were enrolled in the study.
Group A when an intraperitoneal drain was placed and Group B when not.
Placement of drains does not facilitate detection of staple line, leak, abscess, or bleeding. Furthermore, they don't seem to eliminate the reoperation rates for these complications.
Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients
Konstantinos et al Obesity surgery .july 2011

19. Take Home Messages
Distal leak is different from proximal leak The use of green stapler for the pylorus is preferable. Avoid the use of cautery on staple line. The routine use of UGI series and Drains is no longer a routine. Close and aggressive management may be the only chance to save your patient’s life.

21. LAPAROSCOPIC SLEEVE GASTRECTOMY . LEAK AND ITS MANAGEMENT.
LITERATURE REVIEW

22. Sleeve gastrectomy was initially conceived and first described in 1988 by Hess and Marceau as a restrictive component of the BPD–DS.
In 1999, Gagner et al. performed LSG, which was considered a bridging procedure in super-morbidly obese patients to be followed by a second definitive procedure such as RYGB or BPD–DS.
Laparoscopic Sleeve Gastrectomy: a First Step for Rapid Weight Loss in Morbidly Obese Patients Requiring a Second Non-Bariatric Procedure Jesus E. Hidalgo & Mayank Roy & Alexander Ramirez & Samuel Szomstein & Raul J. Rosenthal OBES SURG DOI /s z

23. The sleeve gastrectomy is now most commonly used as a stand alone operation performed laparoscopically.
Matthew M. Hutter,∗ Bruce D. Schirmer, et.al .First Report from the American College of Surgeons Bariatric Surgery Center Network Annals of Surgery Volume 254, Number 3, September 2011

24. Weight loss following LSG is achieved by both restriction and
hormonal modulation.
Firstly, reduction in stomach size with the sleeve resection restricts distention and increases the patient’s sensation of fullness (decreasing meal portion size). This restriction is further facilitated by the natural band effect of the intact pylorus which is maintained during the sleeve gastrectomy.
Reduction in the hunger drive of patients that may be related to decreasing serum levels of ghrelin, a hormone produced mainly by P/D1 cells lining the fundus of the human stomach which stimulates hunger.
A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

25. INDICATIONS TO USE LSG Inflammatory bowel disease.
Severe bowel adhesions from previous surgery.
The necessity to continue certain medications, (immunosuppressant or antiinflammatory agents).
Patient refusal to undergo anatomic rearrangement of their intestinal anatomy or placement of an implanted device.

26. ADVANTAGES OF LSG
The stomach is reduced without major changes in continuity.
preservation of the pylorus prevents dumping syndrome and might add to the restrictive component of LSG.
There are no problems with malabsorption and nutritional deficiency as seen in BPD–DS.
Minimal follow-up is required when compared with other well-established procedures such as LAGB and RYGB.
Relative technical ease of performance compared to other bariatric procedures.
Acceptable operative time.
Low complication rate, (reports of average EWL of 51% to 83% at 1 year )
Improvement of comorbidities.

27. First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)
One hundred nine hospitals submitted data on 28,616 patients, from July, 2007 to September, 2010, which were included for this analysis.

28. LRYGB/ORYGB LSG LAGB 15.34 kg/m2 at 1-year 11.87 kg/m2 at 1-year
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

29. loss after the LRYGB/ORYGB but greater than the weight loss after
The absolute reduction in BMI after the LSG is less than the weight
loss after the LRYGB/ORYGB but greater than the weight loss after
the LAGB.
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

30. A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

31. Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure? Ajay Chopra • Edward Chao • Yana Etkin • Lynn Merklinger • Jayne Lieb • Harry Delany Surg Endosc DOI /s

32. 55% have their diabetes resolve or improve 1 year after the LSG,
compared to 44% for the LAGB and 83% for the LRYGB.
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

33. For patients who are hypertensive at baseline, 68% have their
hypertension resolve or improve 1 year after the LSG, compared to 44%
for the LAGB and 79% for the LRYGB.
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

34. LRYGB/ORYGB LSG LAGB 70% at 1-year 50% at 1-year 64% at 1-year
Resolved
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

35. LRYGB/ORYGB LSG LAGB 66% at 1-year 62% at 1-year 38% at 1-year
Resolved
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

36. LRYGB/ORYGB LSG LAGB 66% at 1-year 35% at 1-year 33% at 1-year
Resolved
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

37. Resolution/improvement of comorbidities was 84% for diabetes mellitus, 49.99% for hypertension, 90% for asthma, 90.74% for obstructive sleep apnea, and 45.92% for GERD.
Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure? Ajay Chopra • Edward Chao • Yana Etkin • Lynn Merklinger • Jayne Lieb • Harry Delany Surg Endosc DOI /s

38. A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

39. Thirty-day morbidity rate for LSG (5
Thirty-day morbidity rate for LSG (5.61%) is statistically higher than the
LAGB rate (1.44%), however this is comparable to the LRYGB rate (5.91%).
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

40. positioned between the LAGB (0.05% and 0.08%) and the LRYGB (0.14%
that the mortality rate of the LSG (0.11% at 30 days, 0.21% at 1 year) is
positioned between the LAGB (0.05% and 0.08%) and the LRYGB (0.14%
and 0.34).
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

41. the LAGB (0.92%) and the LRYGB (5.02%), which is significant on both
Reoperation/intervention rates for the LSG (2.97%) are positioned between
the LAGB (0.92%) and the LRYGB (5.02%), which is significant on both
univariate and multivariate analyses.
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

42. First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422

43. A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

44. Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

45. Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure? Ajay Chopra • Edward Chao • Yana Etkin • Lynn Merklinger • Jayne Lieb • Harry Delany Surg Endosc DOI /s

46. Predicting Risk for Serious Complications With Bariatric Surgery
Predicting Risk for Serious Complications With Bariatric Surgery .Results from the Michigan Bariatric Surgery Collaborative Jonathan F. Finks, MD,∗ Kerry L. Kole, DO, et al. for the Michigan Bariatric Surgery Collaborative, from the Center for Healthcare Outcomes and Policy
Ann Surg 2011;254:633–640)

47. In conclusion, data from the ACS-BSCN accredited hospitals show
that the LSG seems to be a safe and effective procedure for the
treatment of obesity and obesity related comorbidities.
At 1 year, complication rates and reduction in weight and weight-
related illnesses for the LSG seem to fall between the LAGB (which
has relatively fewer short term complications, but less reduction
in weight and weight-related diseases), and the LRYGB (which
seems to have relatively more complications, and to be more
effective).
First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

48. According to the UK Surgical Infection Study Group, a gastric leak was defined as “the leak of luminal contents from a surgical joint between two hollow viscera”. Gastrointestinal leak in the staple line lead to distribution of luminal content around the organ.
Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987

49. Classification of leaks
Determining the time of appearance, leaks were classified
according to Csendes et al. in leaks being detected 1 to 3
days after surgery (postoperative days (POD) −3), those
being detected 4 to 7 days after surgery (POD 4–7), and
those appearing more than 7 days after surgery (POD≥8).
Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987

50. Classification of leaks
We have proposed a classification of the leaks based on three
parameters: time of appearance after surgery, magnitude or
clinical severity, and location of the leaks.
Thus, early leaks were classified as those that appeared 1 to 4 days
after surgery.
- Intermediate leaks those that appeared 5 to 9 days after surgery.
- late leaks those that appeared 10 or more days after surgery.
Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

51. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

52. as a localized leak, without spillage or dissemination, with
Types of leaks
Furthermore, type I or subclinical are those that appear
as a localized leak, without spillage or dissemination, with
few clinical manifestations and easy to treat medically.
Type II leaks are those with dissemination or diffusion
into the abdominal or pleural cavity, with the appearance
of contrast medium (methylene blue, radiological
contrast) or food through any of the abdominal drain,
with severe clinical consequences.
Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

53. location of leaks
The analysis of the data clearly suggests that leak primarily
occurs at the proximal portion of the staple-line. Only 52% of
studies documented the location of the leak and 89% of these
were at the esophagogastric junction. This danger zone may be
thinner than the rest of the stomach.
Elariny et al. demonstrated that the stomach has different
thickness throughout with the fundus being the thinnest at
approximately 1.7 mm. This begs the question of whether a
white load (2.5 mm staple height) should be used for the upper
most staples as green loads are used for the antrum because of
its thickness .
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan •Alan A. Saber Surg Endosc (DEC 2011)DOI /s ,

54. location of leaks third and only 14.3% in the distal third.
Burgos et al. reported 85.7% of leaks in the proximal
third and only 14.3% in the distal third.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

55. Mechanisms of leaks
Leaks can be produced by two mechanisms: mechanical and ischemic:
Mechanical mechanism occurs when intragastric pressure exceeds the strength of the staple line.
Devascularization of the gastroesophageal junction during the liberation of the greater curvature could be related to ischemia and difficulty in healing.
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

56. Mechanisms of leaks
Baker suggests that fistulas can be divided into two
categories: mechanical–tissular causes and ischemic
causes. In both situations, intraluminal pressure exceeds
tissular and suture line resistance, thus causing the
fistula.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

57. Mechanisms of leaks
Gastric fistulas are secondary to an impaired normal acute healing process. Local risk factors include impaired suture line healing, poor blood flow, infection, and poor oxygenation with subsequent ischemia.
Some authors suggest that most fistulas are not due to staple failure, and consequently, staple line dehiscence, but are due to ischemia in the gastric wall next to the staple line that may be caused by dissection of the greater curvature when using the Ultracision® or LigaSure® systems.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

58. Mechanisms of leaks
When the cause is mechanical–tissular, fistulas are usually
discovered within the first 2 days after surgery.
Classic ischemic fistulas tend to appear between 5 and 6
days after surgery, when the wall healing process is
between the inflammation phase and fibrotic phase.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

59. .
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan • Alan A. Saber Surg Endosc DOI /s ,DEC 2011 Presented at the SAGES 2011 Annual Meeting, March 30–April 2,2011, San Antonio, TX

60. gastric bypass with minimal risk. leak rate of approximately 2.4%.
This demonstrated that LSG provides comparative weight loss to
gastric bypass with minimal risk.
leak rate of approximately 2.4%.
Clinically significant bleeding and stricture rate of less than 1%.
Leak occurs at the GE junction in 89% of the time.
The risk of leak is greater in patients with BMI[50 kg/m2. Bougie
size of \40-Fr also is associated with increased risk of leak.
Oversewing or buttressing of the staple-line does not have a
clinically significant effect on leak.
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan •Alan A. Saber Surg Endosc (DEC 2011)DOI /s ,

61. clearance at the dreaded esophagogastric junction
Alternatively, using a larger bougie size may give greater
clearance at the dreaded esophagogastric junction
thereby reducing the risk of leak. This may be supported
by the fact that surgeon s who used a bougie size of 40-
Fr or greater had a 0.6% leak rate (5/897 cases).
The leak rate was 2.8% (110/3,991) in groups who used
a bougie size less than 40-Fr(P\0.05). This difference
was statistically significant, thus favoring the use of a
bougie of 40-Fr to avoid leak.
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan •Alan A. Saber Surg Endosc (DEC 2011)DOI /s ,

62. Symptoms of leaks
A sudden onset of abdominal pain was the main symptom in the patients with an early leak. All patients developed tachycardia and fever in conjunction with the pain episode.
Abdominal pain located in the upper portion of the abdomen associated with fever was the first symptom in four patients while two developed respiratory symptoms and the CT findings were interpreted as pneumonia associated with pleural effusion, and treatment was provided for this diagnosis.
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

63. Symptoms of leaks
Leading symptoms of patients with gastric leak were tachycardia,
increased WBC, and elevated C-reactive protein levels.
Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987

64. Symptoms of leaks
Burgos et al. report a series of 7 leaks in 214 patients
(3.3%), of which 5 patients presented with abdominal pain,
fever, tachycardia, tachypnea, and increased laboratory
signs of infection. They observed that tachycardia is an
initial sign of early leak.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

65. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

66. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan •Alan A. Saber Surg Endosc (DEC 2011)DOI /s ,

67. MANAGEMENT OF LEAKS

68. Management of leaks
Leak management depends on the time of the diagnosis. In the case
of leaks detected during the first days of the postoperative period, a
relaparoscopy should be performed.
In some patients, the leak had already spread to the abdominal
cavity, and a complete and thorough cleaning is necessary. Local
factors such as edema, inflammation, and presence of infection
around the defects should be considered.
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

69. Management of leaks
The determining factor for the treatment of gastric leakage
within the first week after LSG is the location of the
leakage and the presence or absence of an
intraabdominal drain. .
Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987

70. Management of leaks
In case of proximal leakage, endoluminal stent graft
application is a promising therapy in the early
postoperative course, irrespective of the exact postoperative
day. In case of absence of an intraabdominal drain,
relaparoscopy with abdominal lavage and insertion of a
drain is necessary
Re-suture or resection of the staple line may be a possible
solution to the problem only in case of distal leakage. .
Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987

71. Management of leaks
In the case of early fistula (<3 days after surgery), and
which is diagnosed promptly, some authors support
primary repair when the defect is easy to identify and
the surrounding tissues are not very inflamed .
Nevertheless, simple primary repair of fistula is associated
with a high percentage of recurrences.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

72. Management of leaks
During the attempt to repair the defect, precaution to avoid stenosis
of the repaired area should be taken into account. Due to the
increased possibility of failure of the resutured stomach, the entire
area must be drained with well-positioned drains. During this same
procedure, a nasojejunal tube must be placed to feed the patient until
the leak heals.
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

73. Management of leaks
Re-suturing the orifice of the gastric leak, early after surgery and
before the third POD, may result in prompt healing and recovery.
After the third POD, tissues are severely inflamed and infected,
and re-suturing results In complete failure.
In these cases, complete and intense abdominal lavage with
saline, the correct placement of drains, and the intraoperative
placement of a nasojejunal feeding tube result in a favorable
clinical evolution.
Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

74. Management of leaks
Late leak often can be managed by percutaneous drainage and endoscopic stenting. Sufficiently powered, prospective, randomized studies are needed to evaluate the role of fibrin glue, staple height, and distance between the GE junction and the staple line independently and in combination on leak and complication after laparoscopic sleeve gastrectomy.
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan •Alan A. Saber Surg Endosc (DEC 2011)DOI /s ,

75. Management of leaks
When a late leak is detected, a collection adjacent to the
remnant stomach is frequently found, and the fluids have
not spread yet to the rest of the cavity. In this case, a
percutaneous drainage of the collection is an alternative.
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

76. Management of leaks
In the case of late fistulas, closure of the defect is not
possible due to the large inflammatory component and
the frequent presence of nearby abscesses. In these cases,
washing out the cavity and placing a drain is the best
option.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

78. Management of leaks
Of the 52 leaks that had a documented time of diagnosis, 40
were more than 10 days postoperatively and thus required
rehospitalization. This suggests that approximately 79% of leaks
will occur as a late event, and the majority will be managed by
minimally invasive means, including endoscopic stenting.
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan •Alan A. Saber Surg Endosc (DEC 2011)DOI /s ,

80. The period of time required for the leak to close ranged from 21 to 240 days from the time of diagnosis (mean 45 days)
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

81. Management of leaks
For leaks occurring in the early postoperative period and for
stable patients, if suction drain offers a proper total extraction of
GI fluid, keeping the patient nil per os and administrating broad
spectrum antibiotics can provide a good conservative
management.
Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients
Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros
OBES SURG (2011) 21:687–691

82. Management of leaks
On the other hand, stable patients with a few symptoms, or those
who develop fistulas after a long postoperative period, can be
managed conservatively by placing a drain, parenteral or enteral
nutrition, high-dose proton pump inhibitors, and the use of broad
spectrum antibiotics. Enteral nutrition should be started as soon as
possible during treatment since appropriate nutrition is needed to
support defect closure.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

83. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

84. Standard CTscan even with oral application of contrast media is
inferior in patients with BMI 50+.
Diagnostic and therapeutic
algorithm in case of suspected gastric leak

85. Stents Employment
In recent years, most authors have supported the use of flexible
coated stents as a second step. In this way, a temporary “fistula
bypass” is obtained enabling enteral nutrition to be maintained
until closure. (Any abscess or intra-abdominal collection should be
previously drained before placing the stent).
Serra et al. report six cases of fistulas following sleeve gastrectomy.
Five were closed by placing a coated self-expandable stent,
whereas one patient treated with a stent required total
gastrectomy after 3 months due to persistent fistula.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

86. Stents Employment Covered stents were used in four patients. In all
patients, drainage output diminished considerably
immediately after inserting the stent. In two patients,
due to the migration of the stent to the lower portion of
the stomach, an endoscopic reinstallation was
necessary. In one of the aforementioned patients, the
stent had to be removed 30 days after being inserted
due to its persistent migration
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

87. Stents Employment
On the other hand, Tan et al. reported a success rate for closure of only 50% with patients requiring premature removal due to complication derived from the stent.
Stents should remain in place for at least 6 weeks before checking if the defect has closed .
The migration index has been reported to be as high as one third of all cases.
The beneficial effect of an endoluminal stent could also be in part explained by the decreasing intragastric pressure
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

91. Management of leaks
Fibrin glue also was used to cover the staple-line by
Bellanger et al. Fibrin glue has been used for endoscopic
therapy of postoperative leaks after sleeve gastrectomy
but has not been documented as a regularly used product
to prevent leak in sleeve gastrectomy.
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora • Leena Khaitan •Alan A. Saber Surg Endosc (DEC 2011)DOI /s ,

92. Management of leaks
Patients who do not respond to any of these procedures
and those with persistent fistula are candidates for three
types of reintervention: conversion to gastric bypass,
Roux-en- Y, or total gastrectomy .
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

93. Management of leaks (conclusion)
Quick recognition of leak is essential, and therefore, a greater state of suspicion is fundamental. After controlling the septic state, efforts must be focused on treating the gastric leak.
A well-drained leak is the cornerstone in the management of this complication. In addition to the latter, enteral nutrition via a nasojejunal tube must be initiated.
Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

94. Management of leaks(conclusion)
The location of leakage, and the presence or absence of an
intraabdominal drain are determining factors for its treatment.
UGI radiography with contrast media and gastroscopy are
comparable and superior to standard CT scan.
Stent graft application is a promising therapy in case of proximal
leakage; re-suture or resection of the staple line are possible
solutions in case of a distal leak.
Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987

95. protocol: 262 women (76.6%) and 81 men (23.4%).
Total of 343 consecutive obese patients were included in this
protocol: 262 women (76.6%) and 81 men (23.4%).
Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients
Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros
OBES SURG (2011) 21:687–691

96. 50% of patients with drain and leak, per os blue de methylene test was
Patients were enrolled in Group A when an intraperitoneal drain was placed
and Group B when not. the differences did not reach statistical significance. In
50% of patients with drain and leak, per os blue de methylene test was
negative and in another 50% leak took place after the fourth postoperative day
when drain was already taken off.
Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients
Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros
OBES SURG (2011) 21:687–691

97. Placement of drains does not facilitate detection of staple line
leak, abscess, or bleeding. Furthermore, they don't seem to
eliminate the reoperation rates for these complications.
Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients
Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros
OBES SURG (2011) 21:687–691

98. Prevention of leaks
Baltasar et al.protect the staple line with a continuous
sero-serous suture (from the angle of Hiss to the half-
way point, and a second continuous suture from this
point to the end) that inverts the staples, controls
bleeding, and reduces the number of leaks, without
increasing the cost of the procedure .
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

100. Prevention of leaks
Another fistula prevention technique involves using
fibrin sealants (Tissucol®, Vivostat®) along the Several
studies have reported that these materials reduce the
number of leaks staple line.
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

102. How can a leak be prevented?
It is obvious that general surgical principles such as the careful
selection of patients, the experience of the surgeon, gentle handling
of tissues, adequate selection of surgical techniques, and avoidance
of stricture at the mid or distal portion of the tubular stomach are
very important details.
Also careful management of electrocautery and vessel sealing
systems is essential, because thermal damage is one of the most
important pathogenetic factors.
Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

103. How can a leak be prevented?
When using endostaples, it is advisable to begin tissue
compression carefully and sustain this position for
enough time to allow the tissue fluids to exit, as well
as to carefully place the staples . Some authors advise
waiting for around 10 s before beginning stapling. .
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311

104. The healing time of a gastric leak after a sleeve gastrectomy is
significantly longer than the healing time of a leak after a gastric
bypass (45 vs. 30 days, respectively).
However, the reason for that is :
After a gastric bypass, the only fluid that is collected through the
drain is saliva, because gastric juice is nil in the gastric pouch and no
reflux of intestinal content is present due to a long Roux-en-Y limb.
On the contrary, in patients with a sleeve gastrectomy, in addition to
the presence of saliva, there is residual gastric acid secretion and
eventual reflux of duodenal content through an open pylorus.
- Secondly, an increased intraluminal pressure has been described
after lSG that could contribute to the development of a leak, which is
not present in gastric bypass.
Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity
Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos
J Gastrointest Surg (2010) 14:1343–1348

105. Initial Experience with Robotic Sleeve Gastrectomy for Morbid Obesity Theodoros Diamantis & Andreas Alexandrou & Nikolaos Nikiteas & Athanasios Giannopoulos &Eustathios Papalambros OBES SURG (2011) 21:1172–1179

106. CONCLUSION
The distance from the pylorus for the first stapler application, means of dissection of the greater gastric curvature, the size of bougie used for the splinting of stomach, the kind of staplers and the appropriate size of the clips, the necessity and the way of reinforcement of the staple line, the ideal volume of the residual stomach, the proximity of the end of the resection line to the angle of His, the routine use of intra-operative leakage test, and the use of drains, all are issues of debate among the various reporting authors.
Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopic Guidance. Immediate Peri-operative and 1-year Results after 25 Patients T. Diamantis & A. Alexandrou & E. Pikoulis & D. Diamantis & J. Griniatsos & E. Felekouras & E. Papalambros OBES SURG (2010) 20:1164–1170

107. THANK
YOU

108. Classification of leaks
leak has been classified in the literature based on the period in
which it appears:
– Early: leaks that appear between the first and third day after surgery.
– Intermediate: leaks that appear between the fourth and seventh day
after surgery.
– Late: those that appear more than 8 days after surgery
Gastric Leak After Laparoscopic Sleeve Gastrectomy
Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet
OBES SURG (2010) 20:1306–1311