Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm

Abstract

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed 'standalone' bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at our institution.

Patients and methods: From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed.

Results: Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality.

Conclusion: Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.

Figure 1

(a) Cross section of contrast enhanced computed tomography scan scan showing a well-formed fistulous tract leading from the mid-sleeve to the midline laparotomy wound (b and c) Intraoperative photograph showing the gastro-cutaneous fistula opening at midline laparotomy scar with a nasogastric tube threaded across seen to arise from a large mid-body fistula at laparotomy (d) Intraoperative photograph showing the side-to-side fistula loop gastro-jujenostomy

Figure 2

(a) Cross section of contrast-enhanced computed tomography scan showing a left sub-diaphragmatic collection with air within, with no leak of contrast (b) Intraoperative photograph showing sutured repair of the fistula site (c and d) Intraoperative photograph showing creation of a gastric pouch by dividing the sleeve across and conversion to a Roux-en-Y bypass

Figure 3

(a) Cross section of contrast-enhanced CT scan revealed a sub-diaphragmatic collection suggestive of a haematoma with a small leak of contrast within the haematoma (b) Intraoperative view of staple line haematoma (c) Intraoperative photograph showing the stomach just beyond oesophago-gastric junction being re-sleeved with a linear stapler (d) Intraoperative photograph showing site of staple line bleeding managed by suture ligation

Figure 4

(a) Coronal section of contrast-enhanced computed tomography scan showing a sub-diaphragmatic collection with leak of oral contrast within draining to a bronchus in the left postero-basal segment on contrast study (b) Intraoperative photograph showing sutured repair of the fistula site (c and d) Intraoperative photograph showing creation of a gastric pouch by dividing the sleeve across and conversion to a Roux-en-Y bypass

Figure 5

Clinical algorithm for management of gastric sleeve leaks, *Fistula Roux-en-Y jujenostomy may be used if a distal stricture is suspected or instead of a Roux-en-Y bypass