Endoscopic management of leak following sleeve gastrectomy: case series and literature review

Background: There has been an increase in the use of sleeve gastrectomy for operative weight management, and a parallel increase in the incidence of post-operative leak. There is no accepted classification system or treatment algorithm for these leaks, and the management is often multistep and multidisciplinary. We aim to assess the endoscopic strategies for leak management and review the literature on attempts to classify staple line leaks

Methods: Two representative complex cases of leaks following sleeve gastrectomy managed endoscopically are reviewed. Additionally, a systematic electronic review of the literature using the MEDLINE database and individual reference checks yielded 5 studies between 2012 and 2015 discussing institutional experiences with endoscopic management of sleeve gastrectomy leaks. Keywords included “sleeve gastrectomy”, “leak”, and “endoscopic”. An additional 4 studies proposing classification and management schemes for leaks were reviewed.

Results: Our endoscopically managed cases presented with leaks at post-operative days 67 and 12. One patient underwent initial surgical repair and drain placement without resolution. All other interventions were endoscopic and both patients achieved leak resolution on post-operative days 137 and 98 respectively. Of the 5 articles reviewed, the total number of patients with leaks treated endoscopically were 47. The percentage of sleeve gastrectomy patients with leaks ranged from 1.5-2.8%. The average time to leak ranged from 7-27.2 days. The initial endoscopic intervention for all but one patient was stenting. Of the patients treated endoscopically, 34 (72%) achieved leak resolution with only endoscopic intervention. Classification methods have been proposed using post-operative day, CT findings of collection size, number of collections, CT evidence of leak, and leak size, but no method has been consistently validated.

Conclusion: Endoscopic treatments for staple line leak in sleeve gastrectomy are less invasive approaches to achieve leak resolution. Continuing to treat patients endoscopically will provide more information on outcomes to better guide decision making and to propose an accepted classification system and algorithm for management.