Initially, all patients will be diagnosed on CT imaging; types of intervention then depend on the patient’s stability, regardless of timing of presentation, as illustrated in Figure 1. Another method utilized at our institution was OTSC, which was utilized in four patients but only as the last intervention in one patient. At our institution, we have used various methods reported in the literature to mitigate staple line leak. The longest recovery time was three months in a patient treated with E-Vac sponges whose course was complicated by acute respiratory failure requiring percutaneous tracheostomy placement for ventilatory weaning.
Three patients required operative intervention after initial management, one of whom was initially managed surgically and the other two were initially managed endoscopically. Of these 10 patients, three underwent initial surgical intervention for washout and drainage; two of the three subsequently underwent concurrent feeding jejunostomy tube placement. Initial management of patients who presented with leak was based on clinical presentation and initial CT imaging. All patients from a three-surgeon bariatric group who were diagnosed with staple line leak after laparoscopic sleeve gastrectomy between January 1, 2010 and December 31, 2019 were included in the analysis. Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution.
- Initially, all patients will be diagnosed on CT imaging; types of intervention then depend on the patient’s stability, regardless of timing of presentation, as illustrated in Figure 1.
- Increased operative time and cost with intracorporeal suturing is supported in other studies that reported an additional 13 to 24 min per case.
- Nausea, or more commonly persistent gastroesophageal reflux disease, are two indications for conversion of LSG to Roux-en-Y gastric bypass, regardless of the status of postoperative staple line leak from LSG.4 Of note, there was one mortality in this series of patients which occurred approximately two years after LSG and was unrelated to complications from staple line leak.
- We retrospectively reviewed all patients who underwent LSG as a primary operation at the Bariatric Unit of Tor Vergata University Hospital in Rome from 2007 to 2015.
- Inserting an additional nasogastric tube into the Roux limb can assist in keeping the anastomosis open while enabling enteral feeding, which can aid in a more rapid improvement of the patient’s condition .
- Our retrospective, single-center study aims to evaluate the prevalence of postoperative staple line leakage after LSG and identify risk factors for its development, with a focus on acute (before the 7th postoperative day) leaks.
In all cases the leaks were located at the gastrooesophageal junction area, along the suture line. The mean operative time was 93 minutes (range 60–170 minutes; SD ± 43.82) and the mean length of stay 3.8 days (range 3–5 days; SD ± 0.84). The mean BMI was 45.90 Kg/m2 (range 27.68–70.0 Kg/m2; SD ± 7.47); the mean operative time was 85.42 minutes (range 45–205 minutes; SD ± 32.42) and the mean length of stay was 3.55 days (range 2–14 days; SD ± 1.63). From 2007 to 2015, 418 patients underwent LSG (159 males, 259 females). A week later, all patients returned to the outpatient clinic for the first follow-up appointment. An intraoperative staple line test with methylene blue was performed using the orogastric tube.
If the surrounding tissue is non-brittle, it may be possible to close the leak site with suturing. Although CT-guided drainage is the preferred initial method, a transthoracic approach may be necessary because the abscess cavity is located below the left diaphragm and near the angle of His. In addition, there are limitations to the modalities that can be used for treatment, depending on the country and region. Therefore, it is crucial to remember that if complications are not promptly managed, a patient’s general condition can rapidly deteriorate.
Nausea, or more commonly persistent gastroesophageal reflux disease, are two indications for conversion of LSG to Roux-en-Y gastric bypass, regardless of the status of postoperative staple line leak from LSG.4 Of note, there was one mortality in this series of patients which occurred approximately two years after LSG and was unrelated to complications from staple line leak. Despite leakage, all patients in this series experienced appropriate postoperative weight loss after LSG. When staple line leaks do occur, patients often present peritonitic and septic, and intervention is determined by the both the stability of the patient and the extent of leak. The variety of treatment strategies, tailored to different patient-types, suggests that there is not a single best method to manage staple line leaks from LSG. Eight patients required at least two interventions, which highlights the difficult nature of managing sleeve leaks.
Table 3.
This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. This systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Staple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Based on our experience, we suggest the following flow chart for the treatment of staple line acute and early leaks after LSG.
Within this patient cohort, 26 patients (6.46%) developed a postoperative staple line leak. Time-to-event analysis was also utilized to evaluate the different treatment approaches of postoperative leaks. To evaluate the utility of drain amylase levels in the timing of leak diagnosis, the Cox proportional hazards regression was used to build time-to-event models for the occurrence of staple line leaks as seen in Figure 1. The overall time-to-resolution was calculated based on the sum of hospitalization days, over all readmissions, which was required for the complete resolution of the gastric leak. Length of initial hospital stay was defined as the number of days from the first presentation of a gastric leak, until the successful discharge of the patient, able to tolerate oral feeding.
Study Limitations
Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss.
Institutional Review Board Statement
This study was not designed to evaluate costs in relation to leak or bleeding complication. The collection of granular data such as the use of reinforcement on the entire staple-line versus selective areas, the use of buttressing material on both the cartridge and anvil side versus one side or the other, stapler type, and staple height would have been beneficial. This current review highlights that the leak rate for studies conducted in the US were lower than the overall average leak rate of all studies evaluated. Laparoscopic sleeve gastrostomy is a popular operation, and in the US, LSG has surpassed Roux-en-Y gastric bypass because of more favorable outcomes of lower mortality and overall morbidity, similar weight loss, and resolution of health comorbidities at 5 years 163–166. APM absorbable polymer membrane, BPS bovine pericardial strips, max maximum, min minimum, N number of studies reporting variables, NO-SLR no staple-line reinforcement, seal tissue sealant, suture oversewing alone
Figure 1.
Additionally, population and surgical variables of gender, age, body mass index (BMI), calibrating bougie size, and distance between the pylorus and gastric transection line were collected. Electronic results were screened by title to exclude duplicate studies and the remaining records were screened by reading abstracts. The search strategy used for this current review was consistent with our systematic review reported in 2014 and was aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) 13, 15.
3. Statistical Analysis
In our case, election of a smaller diameter bougie that results in a narrow gastric tube, also predisposes to higher intraluminal pressures that might contribute to a small increase in staple line leak rates. Postoperative leakage after SG is commonly classified based on time of occurrence post-surgery. There are two meta-analyses available on the subject, with equally contradictory conclusions regarding bougie sizes and the risk of postoperative staple line leaks . Crude preoperative BMI and BMI of more than 50 were not found to be positively related to the occurrence of postoperative leaks in our patient group (Table 6).
- Within this patient cohort, 26 patients (6.46%) developed a postoperative staple line leak.
- In revisional surgery, the surgical risk is higher than that during the initial surgery due to tissue hardening, edema, adhesion, and increased bleeding propensity.
- It is estimated that anastomotic leakage occurs in approximately 1–3% of the patients with preoperative BMI being an effector for slightly higher rates of leakage occurrence .
- This is possibly attributed to microvascular damage in diabetic patients leading to micro ischemic damage along the staple line, causing leakages to occur.
Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy
When comparing the leak rates from the current analysis to the previous review, it is interesting to note the reliability of the data between both studies . At least one of the three patient characteristics variables (age, gender, or starting BMI) were reported in all but the following eight studies representing 12,473 patients 24, 28, 49, 63, 76, 97, 144. Analysis objectives centered on 5 reinforcement methods NO–SLR, suture, BPM, tissue sealant seal, APM and the number of patients with leak and without leak; bleeding, overall complications, and mortality were collected as text fields but not categorically summarized. Full-text articles were included only if an LSG procedure, leak data, and type of staple-line reinforcement were reported.
2. Total or Proximal Gastrectomy
In addition, the intragastric pressure of the sleeved stomach is higher than that of the normal anatomy. The upper part of the sleeved stomach, especially around the angle of His, has lower blood flow and thinner gastric walls than other areas of the stomach. Laparoscopic sleeve gastrectomy (LSG) is a seemingly simple surgical procedure that involves the removal of 70% of the greater curvature of the stomach and is the only bariatric and metabolic surgery (BMS) covered by insurance in Japan. The authors suggest increasing education and collaboration between healthcare professionals to optimize management and improve patient outcomes. The Bioethics Committee ensured study data anonymization, appropriate handling and data dispersion.
In our cohort, abnormal amylase levels were detected in eight out of the twenty-six patients (30.6%) that were diagnosed with a staple line leak. The definition of abnormal amylase drain levels in our study was amylase levels higher than three times the value of patient serum amylase. The demographic characteristics of leak vs. non-leak patients can be seen in Table 1.
In all likelihood, the true etiology of leaks is a combination of both theories. Damage to tissue during these maneuvers causes daman game app weakening and breakdown of the stomach wall, causing leakage. Consequently, leaks tend to occur in the proximal portion of the stomach near the gastroesophageal junction.7–9 Ischemia at the staple line is presumably caused by both the dissection required to release the stomach, combined with the stapling itself. Most patients required multiple interventions with an average of 2.4 interventions per patient. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution.
As a primary aim of our work, we set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. Patients that were treated for any postoperative complication other than leakage (e.g., staple line bleeding) were not included in the study. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. As APM and Suture were the two reinforcements with the lowest leak rates, this comparison warrants further study.
High-quality data from RCTs have shown no statistically significant difference in anastomotic dehiscence in patients with and without intra-abdominal drains, as the current trend recommends the use of intra-abdominal drains only in complicated or revisional cases. Patient risk factors that are found in the literature to significantly contribute to leakage rates, include male sex, BMI of more than 50 kg/m2, use of SG as a revision procedure, and presence of sleep apnea 36,37,38. Experienced surgeons also seem to agree that another cause of postoperative leaks is the creation of an ischemic environment on the staple line, particularly close to and around the angle of His. The mechanics of staple line leakage, include a long stapling line being present, as well as the conversion of the stomach itself into a narrow, high-pressure tube due to the presence of both esophageal and pyloric sphincters. Our study focused on acute and early leaks, with a few reports on late and chronic leaks that are largely thought to be governed by different pathophysiological principles. Single-institution studies are consistently producing contradictory results either in favor of or indifferent towards increased leak rates with narrower bougie sizes 25,26.
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