You are here
Effectively managing gastric leaks post-LSG
Effectively managing gastric leaks after laparoscopic sleeve gastrectomy (LSG) requires a multidisciplinary team that chooses the proper treatment depending on clinical stability and on the presence or absence of abscess, according to a study by researchers from the University of Rome Tor Vergata, Rome, Italy. They state that their treatment protocol was associated with low complication rate and minor discomfort to the patients, reducing the need for more invasive procedures.
The study, ‘Integrated Approaches for the Management of Staple Line Leaks following Sleeve Gastrectomy,’ published in the Journal of Obesity, was design to try and establish a final flow chart for the management of gastric leaks after laparoscopic sleeve gastrectomy, based on the researchers cases over ten years of patients who received a primary LSG.
“Bariatric surgeons have not reached yet a general consensus about the best management of staple line leaks following LSG….Gastric staple line leak is the most important complication of LSG and can be life threatening, with prolonged intensive care unit hospitalization, reoperations, and even mortality,” the authors note. “Early diagnosis, management, and treatment of a gastric leak after LSG are difficult and still a matter of debate.”
They 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. All patients were evaluated before surgery by a multidisciplinary team including surgeons, endocrinologists, psychiatrists, nutritionists, and anaesthesiologists.
Preoperative work-up included esophagogastroscopy, barium swallow, blood samples, chest X-ray, electrocardiogram, and when needed spirometry, echocardiography, and polysomnography. Psychiatric counselling was conducted with the aim of excluding patients unsuitable for surgery due to mental health contraindications.
They collected demographic, comorbidity, surgical, weight, height, BMI, admission information, imaging tests, complications, and re-operations data. All LSGs were performed by the same surgical team using a standard technique.
From 2007 to 2015, 418 patients underwent LSG (159 males, 259 females). The mean BMI was 45.90 (range 27.68–70.0; 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). All procedures were performed laparoscopically with no conversion to open surgery. No major intraoperative complications were recorded and neither intraoperative nor perioperative deaths within 24 hours after surgery were noted.
There were six staple line leaks (1,44%), in two females and four males. They had a mean BMI of 45.44 (range 34.29–69.20; SD ± 13.79). 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 interval between surgery and readmission for clinical presentation of leak was 13.4 days (range 6–34 days, SD ± 11.85).
There was one acute leak (presentation six days after sleeve gastrectomy) and five early leaks (presentation 7–34 days after surgery). No significant risk factor was found.
In all cases the leaks were located at the gastrooesophageal junction area, along the suture line. Only one of the patients with leak (16.67%) had staple line reinforcement during surgery.
In the first patient of the series readmitted with a leak, there were septic shock and massive pulmonary embolism, and the drainage of peritoneum was achieved by laparotomy. An attempt to close the gastric defect was also performed. This patient died because of sepsis and respiratory distress (global mortality 0.2%, fistula correlated mortality 16.67%).
Two patients had clinical stability and intra-abdominal abscess and underwent CT guided percutaneous drainage. After the resolution of the abscess, confirmed by CT, it was placed an endoscopic gastrooesophageal stent with complete resolution.
Three patients were accepted to A&E in shock condition due to fistula; then they were treated by laparoscopic approach. The nasogastric tube was placed on arrival in A&E and removed early at the time of endoscopy and stent placement. The reoperation was followed by endoscopic gastrooesophageal stenting.
In all cases the endoluminal stent was a covered self-expanding metal Beta Stent (Taewoong Medical) 20cm long and 24mm in diameter, because even though it was closest to the bougie, the gastric pouch has, also in consideration of the elasticity of the stomach, a larger diameter.
The proximal portion of the stent was positioned in the oesophagus, while the distal portion was at the antrum-pyloric region.
When the diameter of the oesophagus was too wide and sufficient anchorage could not be obtained, they proceeded to the placement of a silk thread anchored to the stent and brought out of the nose.
The upper portion of the stent was positioned in the distal oesophagus and the inferior one in the stomach below the leak point. Of the five patients treated with stenting in three cases the stent was repositioned for minor displacements. No further postoperative complications were observed. The mean time for resolution of the leaks was 55.5 days (range 26–83 days; SD ± 25.44).
“When the diagnosis of a gastric leak is made, it represents a challenge for the bariatric surgeon, who needs to decide among different approaches: conservative, percutaneous, or surgical exploration, write the authors. “If an exploratory laparoscopy is performed, it should be done in order to drain the area where the leak is from, wash out the infected fluid, and collect sample for bacterial cultures.”
They suggest that when presented with an uncontained leak, or one associated with hemodynamic instability, requires urgent operative intervention, the following flow chart for the treatment of staple line acute and early leaks after LSG (Figure 1). The treatment protocol was designed according to the international sleeve gastrectomy expert panel consensus statement.
In addition, they write that if there is clinical stability and no evidence of intra-abdominal abscess the patient should be treated with conservative treatment with fasting, total parenteral nutrition, intravenous antibiotic treatment, and gastrooesophageal stent placement.
If there is clinical stability and evidence of an intra-abdominal abscess this treatment should be preceded by a CT guided percutaneous drainage. If you do not have a biochemical response at 48 hours we proceed to exploratory laparoscopy.
Conversly, if the patient comes to A&E with septic shock, the first treatment should be represented by a laparoscopic exploration with washout and drainage, in order to remove the infected collection, and when clinical stability is obtained the patient treatment can be completed by fasting, total parenteral nutrition, intravenous antibiotic treatment, and stent placement.
“Sleeve gastrectomy is an effective and relatively safe procedure for morbid obesity,” the researchers conclude. “…In consideration of the small number of leakages, further studies, based on larger series of morbidly obese patients, are needed in order to validate this approach.”
To access this paper, please click here