Gastric leaks post sleeve gastrectomy: Review of its prevention and management

Abstract

Gastric sleeve gastrectomy has become a frequent bariatric procedure. Its apparent simplicity hides a number of serious, sometimes fatal, complications. This is more important in the absence of an internationally adopted algorithm for the management of the leaks complicating this operation. The debates exist even regarding the definition of a leak, with several classification systems that can be used to predict the cause of the leak, and also to determine the treatment plan. Causes of leak are classified as mechanical, technical and ischemic causes. After defining the possible causes, authors went into suggesting a number of preventive measures to decrease the leak rate, including gentle handling of tissues, staple line reinforcement, larger bougie size and routine use of methylene blue test per operatively. In our review, we noticed that the most important clinical sign or symptom in patients with gastric leaks are fever and tachycardia, which mandate the use of an abdominal computed tomography, associated with an upper gastrointrstinal series and/or gastroscopy if no leak was detected. After diagnosis, the management of leak depends mainly on the clinical condition of the patient and the onset time of leak. It varies between prompt surgical intervention in unstable patients and conservative management in stable ones in whom leaks present lately. The management options include also endoscopic interventions with closure techniques or more commonly exclusion techniques with an endoprosthesis. The aim of this review was to highlight the causes and thus the prevention modalities and find a standardized algorithm to deal with gastric leaks post sleeve gastrectomy.

Keywords: Gastrectomy; Bariatric surgery; Obesity; Anastomotic leak; Gastric fistula; Algorithms; Laparoscopy

Core tip: Gastric leak is one of the most feared complications after a sleeve gastrectomy. Routine oversewing of the staple line decreases the hemorrhagic complications but may not decrease the leak rate. Fever and tachycardia are the two most important clinical factors in the detection of gastric leaks and should never be neglected. The treatment modality should be based on the clinical status of the patient and the timing of the leak. Complete endoscopic approach via natural orifices transluminal endoscopic surgery, diversion using a stent and closure with glue or clips is a reasonable option in selected patients and specialized centers.