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LSG and leaks

LSG leaks: intervene early to avoid complications

Current devices such as stents, clips, T tube are still unsatisfactory

Although leaks following laparoscopic sleeve gastrectomy are uncommon early intervention is vital in acute patients to avoid further complications and complete gastrectomy, according to Mr Marco Adamo, of the Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospital, who was speaking at the 3rd Homerton Bariatric Meeting, in London, UK.

“Laparoscopic sleeve gastrectomy is becoming increasing popular and although surgical experience is improving, the procedure still remains a very new procedure for most surgeons, “said Adamo. “Staple line leaks are a well-known issue, their cause however remains uncertain, probably due to the different techniques and there is a varying incidence of leaks.”

There are several hypothesis as to the aetiology of why leaks occur including the mechanical hypothesis, ischaemia hypothesis, the involvement of the gastro-oesophageal junction in staple line and the high pressure exerted by the pyloric antrum.

“However, none of the suggestions for preventing leaks are completely satisfactory,” said Adamo.

For example, improved stapling technology and utilising large bougies (>32Fr) should address leaks if they are caused by mechanical failure, however, despite these changes, leaks are still possible and antral resection is not beneficial.

It has been suggested that ischaemia results from limiting vascular supply to the angle of His. However, Adamo explained that this has not been proven and the same dissection and stapling is proven in a gastric bypass procedure, and so is insufficient to explain why leaks occur after a sleeve procedure.

In addition, it has been suggested that the involvement of the gastro-oesophageal junction in staple line can be ameliorated by “drifting” to the spleen for last stapling and angling staplers for the last firing. This should allow the gastro-oesophageal junction to be fully-identified. Nevertheless, leaks occur after all these changes.

Management

Adamo's his own experience of treating 12 LSG leak cases (nine of which were cases that occurred in his centre, <1.5% incidence); seven were early leaks (six acute abdomen, one non-acute abdomen) and five late (two acute abdomen, three non-acute abdomen).

In the acute abdomen cases, he said patients received laparoscopic wash-out and drainage followed by enteral/perenteral feeding. Half of the early leaks (n=3) were closed (two patients developed chronic fistula and one had a gastrectomy-bypass). The two patients treat for late leaks did not respond to treatment - one developed a chronic fistula and one had a gastrectomy-bypass).

In the non-acute abdomen cases, patients received CT drainage /+ stent and enteral/perenteral feeding. The early leak (n=1) was closed (although the patient developed a chronic fistula). In the late leaks (n=2), one patient responded to treatment and one developed a chronic fistula.

“Laparoscopic sleeve gastrectomy leaks are difficult to treat due to high pressure closed system and a simple washout and drainage is effective in only 50% of early leaks,” Adamo concluded. “All current devices such as stents, clips, T tube are still unsatisfactory. Ultimately, early intervention is vital in acute patients to avoid serious complications such as fatalities.”

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