Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post–sleeve gastrectomy fistula

Comparison of long-term quality of life outcomes between endoscopic vacuum therapy and other treatments for upper gastrointestinal leaks

BACKGROUND

While endoscopic vacuum assisted closure (EVAC) therapy is a validated treatment for gastrointestinal leaks, its impact on long-term quality of life (QoL) is uncertain. The purpose of this study was to evaluate the impact of successful EVAC management on long-term QoL outcomes.

METHODS

An institutional review board approved prospectively maintained database was retrospectively reviewed to identify patients undergoing treatment for gastrointestinal leaks between June 2012 and July 2022. The Short-Form 36 (SF-36) survey was used to assess QoL. Patients were contacted by telephone and sent the survey electronically. QoL outcomes between patients who underwent successful EVAC therapy and those who required conventional treatment (CT) were analyzed and compared.

RESULTS

A total of 44 patients (17 EVAC; 27 CT) completed the survey and were included in our analysis. All included patients had foregut leaks with sleeve gastrectomy being the most common sentinel operation (n = 20). The mean time from the sentinel operation was 3.8 years and 4.8 years for the EVAC and CT groups, respectively. When evaluating long-term QoL, the EVAC group scored higher in all QoL domains when compared to the CT group with physical functioning (87.3 vs 69.3, p = 0.04), role limitations due to physical health (84.1 vs 45.7, p = 0.02), energy/fatigue (60.0 vs 40.9, p = 0.04), and social functioning (86.2 vs 64.1, p = 0.04) reaching statistical significance. Overall, patients who achieved organ preservation via successful EVAC therapy scored higher in all domains with role limitations due to physical health (p = 0.04) being statistically significant. In a multivariable regression analysis, increased age and a history of prior abdominal surgery at the time of the sentinel operation were patient characteristics that negatively impacted QoL outcomes.

CONCLUSION

Patients with gastrointestinal leaks successfully managed by EVAC therapy have better long-term QoL outcomes when compared to patients undergoing other treatments.

Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy

BACKGROUND

The most common postoperative complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leak. Even if its rate following LSG has been recently reduced, management of chronic leaks remains challenging.

OBJECTIVE

To present a series of patients treated with laparoscopic Roux-en-Y fistulojejunostomy (LRYFJ) for chronic gastric leak (>12 wk) post-LSG.

SETTING

University hospitals; specialized bariatric surgery units.

METHODS

Data were prospectively gathered and retrospectively analyzed. Parameters of interest were patient characteristics, perioperative data, and postoperative outcomes. Hemodynamically unstable patients and/or presentations of signs of severe sepsis were excluded. Surgical technique was standardized.

RESULTS

Fourteen patients underwent LRYFJ for chronic gastric leak (12 women, 2 men). The mean age was 49.2 years and the mean weight was 88.7 kg with a mean body mass index of 31.1 kg/m². All procedures were successfully performed by laparoscopy except 1 (7.1%) converted to open surgery. The mean operative time was 198 minutes, with a mean estimated blood loss of 135.7 mL and 2 patients necessitating transfusion (14.2%). Mortality was null. Five postoperative complications were noted (35.7%): 2 leaks of the fistulojejunostomy treated by antibiotherapy and endoscopic drainage; 1 perianastomotic hematoma treated by relaparoscopy and antibiotherapy; and 1 pleural effusion and 1 hematemesis both medically treated. The mean length of hospital stay was 14 days. The mean follow-up was 40 months, with all patients being in good health at last contact.

CONCLUSIONS

LRYFJ seems to be a good salvage option in selected patients for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons.

Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center

BACKGROUND

Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients.

STUDY DESIGN

An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed.

RESULTS

There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22.

CONCLUSION

Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.

Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks

BACKGROUND

Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks.

OBJECTIVE

Multiple modalities have been advocated for the treatment of sleeve gastrectomy leak, and there remains no consensus on the best treatment paradigm. For more than 10 years, we have variably attempted luminal occlusive therapies and repeated endoscopic debridement as treatment options. By evaluating the outcomes from these approaches, we aimed to determine whether the first management strategy is superior to the second in terms of outcomes.

METHODS

Patients were analyzed by group (luminal occlusive therapy versus repeated endoscopic debridement). Leaks were then stratified by radiologic appearance on computed tomography, defined as phlegmon, collection, contrast medium leak, or fistula. The primary outcome was length of stay (LOS). Secondary outcomes were comprehensive complication index and the need for resection.

RESULTS

There were 54 patients, with 22 in the luminal occlusion group and 32 in the repeated debridement group. There was no difference in LOS (59.8 ± 41.6 versus 46.5 ± 51.2 days, P = .179) and no difference in the requirement for resection (4 versus 3 resections, p = .425). Subset analysis suggested that patients who underwent operative versus conservative management (P = .006) had a longer LOS. Excluding management strategy, radiologic appearance on admission significantly predicted LOS (P = .0053). Patients presenting with fistula (84 ± 25.4 days) and contrast medium leak (64.1 ± 40 days) had a significantly longer LOS than those diagnosed with phlegmon (13.5 ± 5.5 days). Radiologic appearance was predictive of complication severity (P < .0001) and salvage resection (P = .008).

CONCLUSION

There was no significant difference in outcomes between patients treated with intraluminal occlusion or repeated debridement. Initial radiologic appearance was predictive of LOS and complication severity. This highlights the need for routine use of a validated classification system in studies reporting outcomes and treatment of sleeve leaks.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Roux-en-Y Gastric Bypass for the Treatment of Leak Following Sleeve Gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is estimated to be its most severe complication. An aggressive management with surgical reconstructive procedures can be proposed in patients in whom all the conservative endoscopic techniques fail. The purpose of the present study was to report our experience with Roux-en-Y gastric bypass (RYGBP) as treatment for the chronic leak after LSG.

METHODS

Between January 2013 and July 2019, 17 consecutive patients underwent RYGBP for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach and the definitive surgical repair were carefully reviewed.

RESULTS

Seventeen patients (13 women) with a median age of 39 years (24-67) with a median body mass index (BMI) of 40 kg/m² (30-52) underwent RYGBP for persistent fistula. Sixteen patients had their early LSG performed in another hospital. Eleven patients had an initial endoscopic treatment by pigtail drains following laparoscopic drainage and 6 other patients had the endoscopic stent as the first-choice line treatment. The overall average fistula diagnosis was done at 7.7 months (2-49 months) for 12 patients. For the rest of five patients, the procedure was performed almost in the acute setting (< 30 days). All procedures were performed by laparotomy but one. Five patients had a gastrojejunal anastomosis leak diagnosed by salivary flow in the drainage, but all patients were treated conservatively. No post-operative mortality was recorded.

CONCLUSIONS

Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience, RYGBP approach including the leak site offers a low morbidity rate.

The evolution of surgical treatment for chronic leak following sleeve

BACKGROUND

Leak is estimated to be the most severe complication of laparoscopic sleeve gastrectomy (LSG), with sporadic failure of endoscopic techniques. In such cases, an aggressive management with surgical reconstructive procedures can be proposed to patients in whom all the conservative endoscopic techniques failed.

OBJECTIVES

The purpose of the present study was to report our experience with surgical approach for the treatment of chronic leak after LSG.

SETTING

University hospital, France.

METHODS

Between January 2013-December 2019, 21 consecutive patients underwent reconstructive surgery for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach, and the definitive surgical repair were carefully reviewed.

RESULTS

Twenty-one patients (17 women) with a mean (standard deviation [SD]) age of 42.7 years (9.81) and a mean (SD) body mass index (BMI) of 27.3 (5.2) kg/m² underwent reconstructive surgery for persistent fistula. Seventeen patients (81%) had their early LSG performed in another hospital. Endoscopic treatment was represented by the pigtail drain or stent in 9 cases each, ovesco in 8 cases, and glue for 2 patients. The reconstructive surgery was performed within 6 months in 8 cases; between 6-12 months in 6 cases; between 1-3 years in 4 cases, and >3 years in 3 cases. There were 14 fistulo-jejunostomy (66.7%), 5 Roux-en-Y gastric bypass (23.8%), and 2 total gastrectomies (9.5%). The operative time was between 99 minutes and 5.5 hours (mean = 216.2, median = 225 min). The hospital stay ranged from 5-30 days (mean = 12.67, median = 11 d) and the surgical reintervention rate was 23.8% (5/21 patients), including 1 case of recurrent hemorrhage requiring 3 surgical operations over 1 month of postoperative follow-up. No postoperative mortality was recorded.

CONCLUSIONS

Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience the fistulo-jejunostomy approach shows a low morbidity rate. (Surg Obes Relat Dis 2020;17:278-283.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Laparoscopic revision to total gastrectomy or fistulo-jejunostomy as a definitive surgical procedure for chronic gastric fistula after laparoscopic sleeve gastrectomy

BACKGROUND

Staple-line leaks (SLL) after sleeve gastrectomy (SG) are a rare but serious complication requiring radiologic and endoscopic interventions with varying degrees of success. When failed, a chronic gastrocutaneous fistula forms with decreasing chances of closure with time. Definitive surgical management of chronic SLL after SG include laparoscopic revision to total/subtotal gastrectomy (LTG/LSTG) or a fistulo-jejunostomy (LRYFJ), both with Roux-en-Y reconstruction.

OBJECTIVES

Comparison of SG revisions to LTG/LSTG versus LRYFJ as a definitive treatment for chronic SLL.

SETTING

High-volume bariatric unit.

METHODS

Retrospective review of a prospectively maintained database identified 17 patients with chronic gastric fistula after SG that were revised to either LTG/LSTG or LRYFJ between September 2011 and May 2020. Demographic characteristics, clinical data, quality of life, and laboratory values for both options were compared.

RESULTS

Of the 17 conversions, 8 were revised to LTG/LSTG and 9 to LRYFJ. Mean age and body mass index at revision were 36.85 years (range, 21-66 yr) and 29 kg/m² (range, 21-36 kg/m²), respectively. Average preoperative endoscopic attempts was 5 (range, 1-16). The overall average operation time of revision was 183 minutes (range, 130-275 min) with no significant difference between either conversion options. Mean follow-up time was 46.5 months (range, 1-81 mo) and was available for 10 patients (58.8%). Food intolerance was significantly better after revision to LRYFJ (n = 6/6, 100% versus n = 1/5, 20%, P < .05). There were no significant differences between revisional procedures and laboratory abnormalities.

CONCLUSION

Laparoscopic revision to LRYFJ is a safe and feasible treatment for chronic SLL.

Weight Regain After Gastric Plication: Reoperative Sleeve Gastrectomy or Roux-en-Y Gastric Bypass?-Analysis of 116 Consecutive Cases

PURPOSE

In France, laparoscopic gastric plication (GP) has rarely been utilized as a weight loss procedure. Although relatively safe and efficient, its long-term results are still controversial. The goal of this study is to assess the indications and outcomes of revisional surgery post-GP.

MATERIALS AND METHODS

Between February 2010 and September 2017, patient characteristics undergoing GP were prospectively collected from our database. Failure of conservative treatment or presence of anatomical anomaly explaining weight loss insufficiency was an indication for revisional surgery (RS).

RESULTS

A total of 300 patients were included, 41 patients were lost to follow-up (13.7%), 124 patients (41.3%) had total weight loss (TWL) > 30%, and 116 patients (38.7%) underwent RS. Revisional procedures were laparoscopic Roux-en-Y gastric bypass (RYGB) in 72 patients (62.1%) and sleeve gastrectomy (SG) in 44 patients (37.9%). The median interval to RS was 29 months. The mean operative time was 60 min for the SG and 125 min for the RYGB (p < 0.0001). Mortality was nil. Significant morbidity occurred in eight patients (6.9%) including 4 non-abdominal complications, 1 gastric leak, 1 case of hemorrhage, 1 case of hematoma, and 1 intra-abdominal abscess. The mean length of hospital stay (LOS) was 2.9 days (range, 1-11) for the SG group vs 3.2 days (range, 2-8) for the RYGB group (p = 0.608).

CONCLUSION

GP is associated with a relatively high rate of weight regain or insufficient weight loss. When compared to SG, RYGB seems to be the safer revisional procedure with fewer surgical complications.

Double Baltazar Procedure for Repair of Gastric Leakage Post-Sleeve Gastrectomy from Two Sites: Case Report of New Surgical Technique

BACKGROUND

Staple line leak is one of the most challenging complications following laparoscopic sleeve gastrectomy, with a rate reaching near 1%. Its management often implicates a multidisciplinary approach and experienced bariatric and metabolic surgeons. The literature is abundant on various approaches to treat single staple line leak with variable results. But what to do in front of an intra-op incidental finding of double gastric fistulae?

METHODS

In this article, we describe a new successful surgical treatment option of double Baltazar technique for a patient who was found to have two gastric fistulae post-sleeve gastrectomy. We aim to demonstrate that this approach is safe and effective and can help avoid major side effects of traditional treatment options for such complications.

RESULTS

The patient presented 20 days following a laparoscopic sleeve gastrectomy in a severe septic condition and was found to have a gastric leak. During surgical repair, unlike the usual single proximal fistula findings, another opening was identified more distally. Decision was made to proceed with a double fistulo-jejunostomy. It was a feasible technique, with no intra-op complications. Post-operatively, the patient had a successful recover, with no residual leak.

CONCLUSIONS

Double Baltazar technique is a successful and feasible treatment option for patients presenting with two gastric fistulae following sleeve gastrectomy. This is the first case report describing this new technique, and its success should encourage more similar trials and avoid more aggressive surgical options such as total gastrectomy or gastric bypass.

Endolumenal Vacuum Therapy and Fistulojejunostomy in the Management of Sleeve Gastrectomy Staple Line Leaks

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed for morbid obesity. Leaks of the vertical staple line can occur in up to 7% of cases and are difficult to manage. Endolumenal vacuum (EVAC) therapy and fistulojejunostomy (FJ) have separate documented uses to heal these complicated leaks. We aim to show the benefit of using EVAC with FJ in the treatment of LSG staple line leaks. The patient presented with an LSG chronic leak. EVAC therapy was initiated but failed to close the fistula after 101 days. EVAC therapy was abandoned, and FJ was performed to resolve the leak. Postoperatively, no leak was encountered requiring any additional procedures. Based on our findings, we conclude that EVAC therapy facilitates in resolving leaks that restore gastrointestinal continuity and maintain source control. It promotes healing and causes reperfusion of ischemic tissue and fistula cavity debridement.

Results of Laparoscopic Sleeve Gastrectomy in 541 Consecutive Patients with Low Baseline Body Mass Index (30-35 kg/m2)

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the leading bariatric procedure and targets, among other obesity classes, patients with BMI 30-35 kg/m², which are reaching alarming proportions.

METHODS

Between February 2010 and August 2015, data on 541 consecutive patients with BMI 30-35 kg/m² undergoing LSG were prospectively collected and analyzed.

RESULTS

Mean age was 32 ± 8 years (13-65) and 419 (77.4 %) were women. Preoperative weight was 92.0 ± 8.8 kg (65-121) and BMI was 32.6 ± 1.5 kg/m² (30-35). Comorbidities were detected in 210 (39 %) patients. Operative time was 74 ± 12 min (40-110) and postoperative stay was 1.7 ± 0.22 days (1-3). There were no deaths, leaks, abscesses or strictures and the rate of hemorrhage was 1.2 %. At 1 year, 98 % were followed and BMI decreased to 24.7 ± 1.6, the percentage of total weight loss (% TWL) was 24.1 ± 4.7 while the percentage of excess BMI loss (%EBMIL) reached 106.1 ± 24.1. At 5 years, 76 % of followed patients achieved a ≥50 % EBMIL.

CONCLUSION

With appropriate surgical expertise, LSG in patients with BMI 30-35 kg/m² achieved excellent outcomes with a zero fistula rate.

Roux-En-Y Fistulojejunostomy: a New Therapeutic Option for Complicated Post-Sleeve Gastric Fistulas, Video-Report

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become during the last few years the most frequent procedure in bariatric surgery. However, complications related to the gastric staple line can be even more serious. The incidence of gastric fistula after LSG varies from 1 to 7%. Its management can be very challenging and long. In case of chronic fistula and failure of the previous treatment, total gastrectomy or Roux-en-Y fistulo-jejunostomy (RYFJ) might be considered. RYFJ has been described very rarely as a salvage procedure of gastric leaks after LSG.

METHODS

Between January 2015 and December 2015, we have performed a RYFJ in two patients, with chronic and persisting gastric fistulas, one after LSG and one after duodenal switch, respectively. In the two patients, the RYFJ procedure was attempted laparoscopically but in one case (patient after duodenal switch), conversion into laparotomy was necessary because of severe intra-abdominal inflammatory adhesions. In our video, we are presenting the case of this particular patient treated laparoscopically with a late and persisting leak 1 year after LSG.

RESULTS

In this multimedia high-definition video, we described the steps of our technique of laparoscopic RYFJ. There was neither mortality nor severe postoperative complications. The fistula control after a minimum of 6 months follow-up was 100% for both of patients.

CONCLUSIONS

RYFJ in our particular case was efficient. However, larger series and longer follow-up are needed to confirm the efficiency of the RYFJ as a salvage procedure.

Roux-en-Y fistulo-jejunostomy as a salvage procedure in patients with post-sleeve gastrectomy fistula: mid-term results

BACKGROUND

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure in France. It achieves both adequate excess weight loss and significant reduction in comorbidities. However, fistula is still the most common complication after SG, occurring in more than 3 % of cases, even in specialized centers (Gagner and Buchwald in Surg Obes Relat Dis 10:713-723. doi: 10.1016/j.soard.2014.01.016 , 2014). Its management is not standardized, long, and challenging. We have already reported the short-term results of Roux-en-Y fistulo-jejunostomy (RYFJ) as a salvage procedure in patients with post-SG fistula (Chouillard et al. in Surg Endosc 28:1954-1960 doi: 10.1007/s00464-014-3424-y , 2014). In this study, we analyzed the mid-term results of the RYFJ emphasizing its endoscopic, radiologic, and safety outcome.

METHODS

Between January 2007 and December 2013, we treated 75 patients with post-SG fistula, mainly referred from other centers. Immediate management principles included computerized tomography (CT) scan-guided drainage of collections or surgical peritoneal lavage, nutritional support, and endoscopic stenting. Ultimately, this approach achieved fistula control in nearly two-thirds of the patients. In the remaining third, RYFJ was proposed, eventually leading to fistula control in all cases. The mid-term results (i.e., more than 1 year after surgery) were assessed using anamnesis, clinical evaluation, biology tests, upper digestive tract endoscopy, and IV-enhanced CT scan with contrast upper series.

RESULTS

Thirty patients (22 women and 8 men) had RYFJ for post-SG fistula. Mean age was 40 years (range 22-59). Procedures were performed laparoscopically in all but 3 cases (90 %). Three patients (10 %) were lost to follow-up. Mean follow-up period was 22 months (18-90). Mean body mass index (BMI) was 27.4 kg/m(2) (22-41). Endoscopic and radiologic assessment revealed no persistent fistula and no residual collections.

CONCLUSIONS

Despite the lack of long-term follow-up, RYFJ could be a safe and feasible salvage option for the treatment of patients with post-SG fistula, especially those who failed conservative management. Mid-term outcome analysis confirms that fistula control is durable. Weight loss panel is satisfactory.

Definitive surgical management of staple line leak after sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature.

OBJECTIVES

This study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results.

SETTING

Single surgeon experience based at a tertiary university hospital in Beirut, Lebanon.

METHODS

Retrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013.

RESULTS

Ten patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m(2), respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13-39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1-7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m(2) versus 30 kg/m(2)) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5-55.9 mo) with an average percentage excess weight loss of 74% (57%-120%).

CONCLUSIONS

Definitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.

Management of staple line leaks following sleeve gastrectomy

BACKGROUND

Leaks after laparoscopic sleeve gastrectomy (LSG) are not very frequent but are a difficult complication that can become chronic. Various treatment options have been suggested but no definitive treatment regimen has been established. The aim of our study is to report leak complications after LSG, their management, and outcomes.

METHODS

Between June 2008 and October 2013, a total of 539 patients underwent laparoscopic and robot-assisted laparoscopic sleeve gastrectomy at our institution. A retrospective review of a prospectively collected database was performed for all LSG patients, noting the outcomes and complications of the procedure.

RESULTS

Fifteen (2.8%) patients presented with a leak after LSG. The diagnosis was made at a mean of 27.2±29.9 days (range, 1-102) after LSG. Eight (53.3%) patients underwent conservative treatment initially and 6 (75.0%) of these patients required stenting as secondary treatment. Although leaks from 3 patients resolved with stenting, the other 3 required restenting and 2 eventually underwent conversion to gastric bypass. Five (33.3%) patients underwent endoscopic intervention, closing the leak with fibrin glue (n=3) or hemoclips (n=2). Two (13.3%) patients who were diagnosed with a leak immediately after LSG before discharge had their leak oversewn laparoscopically with an omental patch. Leaks in 9 (60.0%) patients did not heal after the first intervention, and the mean number of intervention required was 2.3±1.7 times (range, 1-7) for the treatment of this condition.

CONCLUSION

Management of leaks after LSG can be challenging. Early diagnosis and treatment is important in the management of a leak. However, it can be treated safely via various management options depending on the time of diagnosis and size of the leak.