HOW I DO IT

Single-Stage Operative Management of Laparoscopic SleeveGastrectomy Leaks Without Endoscopic Stent Placement

Eelaf El Hassan & Awadelkarim Mohamed &

Maha Ibrahim & Maria Margarita &

Mohammed Al Hadad & Abdelrahman A. Nimeri

Published online: 5 March 2013# Springer Science+Business Media New York 2013

AbstractBackground Leaks occur in 1.4–20 % (Bohdjalian et al.,Obes. Surg. 20:535–540, 2010; Nocca et al., Obes Surg.18:560–565, 2008; Stroh et al., 19:632–640, 2009; Auroraet al., Surg. Endosc. 26:1509–1515, 2012) of patients fol-lowing laparoscopic sleeve gastrectomy (LSG). Leaks maylead to major morbidity and prolonged hospitalization. En-doscopic stent placement is a potential management strategythat needs expertise and also has recognized complications(stent migration, significant dysphagia, and failure)(Rosenthal et al., Surg. Obes Relat. Dis. 8:8–19, 2012). Astandard method of managing leaks following LSG has notbeen established. This study aims to evaluate the outcomesof consecutive patients with leaks following LSG managedat BMI Abu Dhabi Tertiary Multidisciplinary Bariatric Sur-gery, Abu Dhabi, UAE.Methods We examined all patients presenting to BMI AbuDhabi between February 2010 and May 2012 with leaksfollowing LSG. Data were obtained from the hospital med-ical record, and IRB approval was obtained. All patientswere managed by utilizing a standardized operative man-agement strategy without the use of endoscopic stenting.Results A total of five patients were referred to us for higherlevel of care; during the same time period, we performed 71

LSGs without a leak. Patients were optimized and resusci-tated adequately before surgery. Intraoperatively, all patientshad endoscopy, and a T tube was placed inside the leak ifclearly identifiable. Otherwise, the leak site was drainedadequately without attempting to place sutures, and ajejunostomy tube was inserted. All leaks healed following aninitial period of hospital stay, followed by an outpatient periodon jejunostomy tube feeding and nil per os.Conclusion Single-stage operative management of leaks af-ter LSG utilizing a standardized operative strategy withoutthe use of endoscopic stenting is both safe and effective.

Keywords Sleeve gastrectomy . Leak . Operativemanagement . Endoscopic stent . Bariatric surgery . BMI .

Abu Dhabi

Introduction

Laparoscopic sleeve gastrectomy (LSG) is considered one ofthe primary surgical options for morbidly obese patients (bodymass index >40 or >35 with comorbidities) [1–7]. Despite thetechnical simplicity of the LSG compared to duodenal switch(DS), biliopancreatic diversion (BPD), and Roux-en-Ygastric bypass (RYGB), leak after LSG is considered tobe one of the major complications with 89 % of leaksoccurring near the gastroesophageal (GE) junction [5].

Leaks after LSG are classified, depending on the durationfrom LSG, to acute (within the first week), early (within thefirst 6 weeks), late (more than 6 weeks), and chronic leaks(more than 12 weeks) after LSG [6]. In addition, gastroin-testinal leaks, in general, are classified according to severityinto three types (A, B, and C). Type A leaks are leaks with amicro-perforation without clinical or radiographic signs of aleak. Type B leaks are leaks without clinical signs but with a

E. El HassanEmergency Residency Program, Sheikh Khalifa Medical City,Abu Dhabi, United Arab Emirates

A. MohamedUAE University, Al Ain, Abu Dhabi, United Arab Emirates

M. Ibrahim :M. Margarita :M. Al Hadad :A. A. Nimeri (*)Department of Surgery, Sheikh Khalifa Medical City, Abu Dhabi,United Arab Emiratese-mail: Nimeri@gmail.com

OBES SURG (2013) 23:722–726DOI 10.1007/s11695-013-0906-2

leak seen on radiographic studies, and type C leaks are thosewith both clinical and radiographic signs [14]. These clas-sifications are important to guide the appropriate manage-ment strategy.

The least invasive management strategy is endoscopicstenting. This option is appealing because it does notinvolve general anesthesia and has been shown to beeffective for early leaks following LSG. However, en-doscopic stenting requires expertise in interventionalendoscopy, is associated with stent migration requiringrestenting in up to 58 % of patients, may fail to healthe leak, is not well tolerated by some patients due todysphagia, and is less effective in chronic leaks follow-ing LSG [9, 12–15]. In addition, the use of endoscopicstents for benign disease is an off-label use of thesestents. A standard method of managing leaks followingLSG has not been established.

Materials and Methods

We performed a retrospective analysis of our prospectivelymaintained database of consecutive patients with leaks afterLSG managed at BMI Abu Dhabi. We identified all patientswith leak documented on radiographic studies after LSG.This is a consecutive series of patients managed by utilizinga standardized operative management without the use ofendoscopic stenting between February 2010 and May2012. The criterion for inclusion was the confirmation ofleak after LSG on a radiographic study (computerized to-mography (CT) scan of the abdomen or an upper gastroin-testinal (UGI) study with contrast medium). We had noexclusion criteria.

All patients had LSG elsewhere and were referred to ourinstitution, BMI Abu Dhabi, for higher level of care. Thefollowing variables were gathered: age, gender, time topresentation in weeks, time to surgery in weeks, type ofoperative intervention, CT-guided drainage, reoperation,hospital stay, and time required for the leak to heal withresumption of oral feeding.

We utilize a standardized operative strategy for LSGleaks at BMI Abu Dhabi. This approach depends onestablishing an enteral feeding route via a jejunostomy tubeand wide drainage of the abdomen without the use of endo-scopic stents.

All patients are clinically and radiographically evaluatedby utilizing UGI studies and CT scan of the abdomen andpelvis with oral and intravenous contrast. Only patients withfree leak of contrast are included. All patients and theirfamilies were counseled about the lengthy process requiredfor the healing of LSG leaks.

All patients are resuscitated and admitted initially to astep-down unit. Nutritional status was assessed and

optimized, and a dietitian was consulted and involved inthe management strategy. They all received broad-spectrumantibiotics, DVT prophylaxis, and adequate pain relief.

The definitive management of the cases involved initialCT-guided drainage if the patient had a large abscessfollowed by surgery.

The surgical procedure is done under general anesthesia.Sequential compression devices are placed before inductionof anesthesia, and preoperative antibiotics and subcutaneousheparin are continued. No naso- or orogastric tubes areplaced. Four ports are placed; an intraoperative endoscopyis done to delineate the leak. If the leak is large, a T tube isplaced. However, if no large hole is found, wide drainage ofthe abdomen with two closed suction drains is done. Finally,in all patients, a feeding jejunostomy tube is inserted, andthe tube is tunneled in the jejunal wall.

After surgery, patients are discharged home, once sepsishas resolved, on jejunal tube feeding with ice chips, gum,and hard candy orally. UGI studies are used to assess theleak healing process on a weekly basis.

Results

A total of five patients were referred to our institution, oneman and four women ranging in age from 25 to 49 years.Three of our cases presented following LSG at a privatehospital in the UAE, one in Egypt, and one in Jordan. Allpatients had leak of contrast documented on radiographicstudies.

All of our five patients were early type C leaks, as theypresented within 6 weeks after LSG, and they had clinicaland radiologic leak of contrast. Three out of five patients(60 %) had LSG after revisional bariatric surgery involvingremoval of laparoscopic adjustable gastric banding (LAGB)and conversion to LSG, while two patients had primaryLSG.

Length of stay (LOS) and outpatient time to healing in4/5 patients was 3–4 weeks and 4–8 weeks, respectively.Table 1 summarizes all five patients.

Discussion

Recently, LSG has become more common and popularas it is a simpler technique than RYGB, DS, and BPDwith a weight loss and complication profile situatedbetween the LAGB and RYGB [8].

Sleeve gastrectomy was first described in 1988 by Hessas a modification of Scopinaro’s technique of the BPD(distal gastrectomy and gastroenterostomy) to the DS oper-ation (sleeve gastrectomy and duodenal switch). Anothermodification was done in 1999 by Gagner performing the

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duodenal switch laparoscopically. Later, LSG was done as afirst-stage procedure for super morbidly obese patients todecrease the morbidity and operative time of the laparoscop-ic duodenal switch. Surprisingly, patients lost 55 % of theirexcess weight and 55 % with resolution of comorbidities[9].

Leaks after LSG lead to major morbidity, and the man-agement strategy is variable and depends on the type and theseverity of the leak (see Fig. 1). Leaks are classifiedaccording to severity [13] or duration from LSG [6]. Allour patients were type C leaks. All our patients presentedwithin 6 weeks of LSG and had clinical and radiographicsigns of leak. In addition, 2/5 (40 %) of our patients werehaving acute early leaks as they had reoperation at thereferring institution within 1 week of LSG.

Our experience is compatible with the fact that 80 % ofLSG leaks are early leaks presenting within the first 4 weeksafter LSG. None of the five patients had surgery at BMI AbuDhabi, and we are not certain when the leaks actuallyoccurred in each patient. In our mind, the operative man-agement strategy is no different if the leak is acute or early.Once a patient has free leak of oral contrast, then oralfeeding is not possible, and a strategy to control the leakand establish enteral feeding is warranted.

The management strategy of leaks after LSG variesdepending on the leak type. Types A and B or late leaksare managed by conservative measures with or withoutradiographic drainage, and type C or early leaks are man-aged by endoscopic stenting or operative intervention [10].

Our approach is based on the establishment of an enteralroute for feeding utilizing a jejunostomy tube, delineation ofthe leak utilizing EGD, and wide drainage of the abdominal

Table 1 During the study period, five patients were referred with LSGleaks. Free leak of oral contrast was demonstrated on UGI study or CTscan. The ages and genders of the patients are presented in the table.

This table also details the time interval between the first operation, thepresentation to BMI Abu Dhabi, and the time at which we operated onthem

Age Gender Initialoperation

Time topresentationin weeks

Time toOR inweeks

Type ofoperativeintervention

CT-guided drainage Reoperation LOS inweeks

Time tohealing inmonths

49 F Revision LAGBto sleeve

6 7a Open resectionof ECF, J tubeand drains

None None 26a 4a

35 F Revision LAGBto sleeve

4 1b Open G tube,J tube

None None 4 1

27 M Revision LAGBto sleeve

5 5 Lap T tube andJ tube, drains

Pre-op andpost op

None 3 2

36 F Primary sleeve 4 4 Lap J tubeand drain

Pre-op only None 3 2

25 F Primary sleeve 4 4 Lap T tube andJ tube, drains

None None 3 1

a Patient referred to our unit in acute renal failure on dialysis, on intubation, and septic with a high output enterocutaneous fistula, a gastrocutaneousfistula, pancytopenia, and severe malnutritionb Patient was operated in another facility and presented to us 3 weeks thereafter

Fig. 1 Upper GI study of a patient presenting with leak post laparo-scopic sleeve gastrectomy

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cavity. Jejunostomy feeding is more appealing than parenteralnutrition for obvious reasons. It is also more appealing thannasojejunal feeding because a patient can be discharged onjejunal feeding even before the leak has completely healed. Inour approach, we did not attempt to suture the leak site, revisethe LSG, or to convert the LSG to RYGB. Our operativeapproach was sufficient in all five patients including thepatient presenting in septic shock, malnutrition, intubatedand on hemodialysis with high output enterocutaneous fistulaand gastrointestinal failure. None of our patients requiredreoperation, and 4/5 (80 %) were discharged within 3–4 weeks; LSG leak healed within 6–8 weeks of outpatiententeral nutrition without intravenous antibiotics.

Another appealing aspect to our operative managementstrategy for LSG leaks is that it allows for better assessmentof the LSG leak, which may alter the operative strategy. Forexample, in the patient that needed T tube placement, theleak was quite large with dehiscence of the staple line at theintersection of the first and second staple firings opposite tothe incisura. This was the only patient with a LSG leak notoriginating from the GE junction. This finding was notobvious on the UGI study and CT scan done prior to sur-gery. In addition, this management strategy allows for earlydischarge of patients once the initial sepsis period is con-trolled, and there is no worry about a stent getting dislodgedor the patient not receiving adequate nutrition.

The time to LSG leak healing in our operative ap-proach is comparable to that using endoscopic stents,percutaneous drainage, and surgery in the publishedliterature. In several studies reporting on LSG leakstreated by percutaneous drainage or operative debride-ment, time of healing is in 3–6 weeks [7, 10, 13, 14].However, not all studies included only early type Cleaks like that of our five patients. The largest patientcollective of 16 patients reported by Csendes et al.showed similar healing time of 6–7 weeks managed bya combination of conservative, percutaneous drainageand operative strategies. However, enteral feeding wasestablished using nasojejunal feeding rather than feeding onjejunostomy tubes. This would preclude discharging patientson enteral feeding once the initial sepsis phase has passed. Inone study, CT-guided drainage alone was sufficient to treat 5/6(83 %) of LSG leaks [11]. In contrast, only 2/5 (40 %) ofour patients needed CT-guided drainage. However, all ourpatients underwent operative drainage. In our opinion, in earlytype C LSG leak patients with free leak of contrast demon-strated on CT or UGI studies, CT-guided drainage must becombined with enteral nutrition either by endoscopic stentingto seal the leak or jejunostomy/nasojejunal tubes.

The use of endoscopic stents to treat LSG leaks is wellestablished in the literature. It is very appealing because itdoes not require general anesthesia, is minimally invasive,and can be repeated more than once. However, endoscopic

stenting is not a panacea; oral feeding resumed in 61 to 79 %of patients in one study and not all patients could maintainadequate calories with oral intake alone. Many patients do nottolerate the stent due to dysphagia, as it was the case in one ofour patients who was transferred from Jordan with a stent inplace and had to have the stent removed due to severe dys-phagia. In addition, the best time for stent removal is un-known, and in most studies, it ranges from 22–88 days afterinsertion; in one study, the mean hospital LOS was more than3 months [9, 14–16, 19]. Furthermore, the expertise for endo-scopic stent placement might not always be available. Ourinstitution is a 700-bed tertiary referral center, but our experi-ence with endoscopic stenting is limited. Furthermore, thepresence of the stent might not always seal the leak to allowfor adequate oral nutrition, and the stent might migrate caus-ing another problem of stent retrieval [9, 14–16]. We feel thatplacing a stent to treat an early LSG leak is acceptable as longas the stent allows for resumption of adequate oral nutritionand adequate caloric intake orally.

It is important to note that 3/5 (60 %) of our LSGleak patients were having leaks following revisionalsurgery involving removal of LAGB and conversion toLSG. It is well documented in the literature thatrevisional bariatric surgery has a higher leak rate thanprimary bariatric surgery [16–21]. In addition, leaksfollowing LSG tend to be more difficult to treat com-pared to leaks following RYGB for several reasons [10].These reasons include the functional obstruction createdby the pylorus, the high pressure system created by thenarrow sleeve tube, and the relatively long LSG stapleline. Revising failed LAGB patients is not our preferredapproach. We prefer to revise failed LAGB patients toRYGB because the weight loss after RYGB is on aver-age a little more than LSG, and it is more difficult totreat a leak after LSG as compared to RYGB for thereasons mentioned above.

The limitations of this study include that it is aretrospective, single-center experience with a small sam-ple size. However, the rate of leakage LSG is generallylow 2.4 % [5], and studies about LSG leaks are usuallyof small series.

Conclusion

A single-stage operative strategy involves wide drainage,and jejunal enteral feeding is safe and effective for earlytype C LSG leaks.

Conflict of Interest The authors of this study (Abdelrahman Nimeri,MD; Mohammed Al Hadad, MD; and Maria Margarita, RN) as well asthe training doctors (Awadelkarim Mohamed, MD; Eelaf El Hassan,MD; and Maha Ibrahim) all have no conflicts of interest to report.

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