Management Algorithm for Leaks Following Laparoscopic Sleeve Gastrectomy.

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Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgery procedure in Asia and the USA (1). The overall morbidity and mortality of LSG is positioned between the laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux en Y gastric bypass (LRYGB) (2).

However, when it comes to leak after LSG, it is more common than leak after LRYGB, it takes longer to heal and it has a higher incidence of becoming a chronic fistula (3).

At BMI Abu Dhabi, we have developed a management algorithm for leaks after LSG (4). This algorithm calls for a different management strategy depending on timing of the leak, presence of stenosis, nutritional status and the clinical presentation of the patient.

In the initial evaluation phase, patients are evaluated radiographically utilizing CT scan of the abdomen and Upper Gastrointestinal (UGI) series followed by upper endoscopy to actively look for stenosis or twist in the LSG. We make sure all collections are drained before performing UGI series.

In summary, patients presenting with leak after LSG are managed either using laparoscopy, drainage, and jejunostomy tube placement (5), or endoscopic stenting (4), or naso-jejunal feeding or laparoscopic Roux en Y esophagojejunostomy (LRYEJ) (6).

For example patients presenting with a demonstrable leak on UGI series without stenosis are treated with either nasa-jejunal feeding or endoscopic stenting. In contrast, patients presenting with stenosis not amenable to endoscopic stenting are treated by LRYEJ. Similarly, patients presenting with chronic leaks (>12 weeks) after LSG are treated by LRYEJ. We utilize enteral feeding oral after stent placement, utilizing a nasa-jejunal tube or utilizing a jejunostomy tube for feeding and we rarely use parenteral feeding in patients with leak after sleeve gastrectomy.

On average, it takes 4-8 weeks for leaks after LSG to heal. We have found psychological support an extremely important aspect of management of these patients. In all patients, we sit down with the patient and their family and we make sure they understand the length of time needed and the possibility for staying without oral nutrition until the LSG leak is healed.

References:

  1. 1. Ponce J1, Nguyen NT2, Hutter M3, Sudan R4, Morton JM5. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in the United States, 2011-2014. Surg Obes Relat Dis. 2015 Nov- Dec;11(6):1199-200.
  2. 2. Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow RP, Nguyen NT. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011 Sep;254(3):410-20; discussion 420-2
  3. 3. Moszkowicz D, Arienzo R, Khettab I, Rahmi G, Zinzindohoué F, Berger A, Chevallier JM. Sleeve gastrectomy severe complications: is it always a reasonable surgical option? Obes Surg. 2013 May;23(5):676-86.
  4. 4. Nimeri A, Ibrahim M, Maasher A, Al Hadad M. Management Algorithm for Leaks Following Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016 Jan; 26(1):21-5.
  5. 5. Single-stage operative management of laparoscopic sleeve gastrectomy El Hassan E, Mohamed A, Ibrahim M, Margarita M, Al Hadad M, Nimeri AA. leaks without endoscopic stent placement. Obes Surg. 2013 May;23(5): 722-6.
  6. 6. Mahmoud M, Maasher A, Al Hadad M, Salim E, Nimeri AA. Laparoscopic Roux En Y Esophago-Jejunostomy for Chronic Leak/ Fistula After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016 Mar;26(3):679-82.

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