Jessica Koller Gorham, MD, Jeffrey Hunter, MD, FACS, Michael Larson, MD. Virginia Mason Medical Center
Sleeve Gastrectomy has become an increasingly common operation in bariatric surgery. In fact, in 2014, sleeve gastrectomy comprised over 50% of bariatric operations in the United States. Post-sleeve gastrectomy leaks are a rare but feared complication, being associated with significant morbidity. This study was designed to review our institution’s experience and successes with endoscopic management of sleeve gastrectomy leaks, and evaluate the potential for an algorithm or protocol. From November 2011 to August 2016, 20 patients with post-sleeve gastrectomy leaks were referred to our institution and managed primarily with endoscopic interventions. A retrospective chart review has been conducted assessing the characteristics of the sentinel operation, endoscopic findings, and management excluding operative revision. Of the 20 patients, two underwent open, thirteen laparoscopic, and five robotic-assisted sleeve gastrectomy. Four patients had undergone previous weight-loss surgery. Eight presented with early leaks within 1 week of surgery, 11 presented between 7 and 33 days post-op. Reviewing the available operative reports, bougie size ranged from 34-40Fr when described, and a variety of buttresses were used including fibrin sealant, omental patches, and over-sewing the staple line. The proximal staple line was the site of leak in 19 cases; one patient had synchronous proximal and distal fistulae. Treatment includes NPO, IV antibiotics, parenteral or jejunal nutrition, percutaneous drainage if appropriate, and a multidisciplinary approach. Endoscopic techniques used to assist closure include WallFlex stents, transgastric pigtail stents, bear claws, fibrin injections, marsupialization, and endoluminal suturing. Four patients only required one intervention. Fibrin injections were never the final step to closure. 19 patients healed after only endoscopic management, and only 1 patient underwent completion gastrectomy with esophagojejunostomy. The median time to closure in primary cases was 0.4 years with 4 interventions, compared to 1.2 years and 6 interventions for revisional cases. In conclusion, leaks following sleeve gastrectomy can be successfully managed with repeat endoscopic intervention. They most frequently occur at the proximal staple line and have a longer and more complex treatment course following revisional bariatric surgery. While the number was too small and the gastroenterology experience too varied to yet make a protocol, we unexpectedly noted a stark difference in the time to closure and number of interventions required when comparing revisional to primary bariatric surgery. This should be discussed with all sleeve gastrectomy pre-op patients who have previously undergone bariatric or foregut surgery, and perhaps earlier surgical intervention is warranted in the event of a leak.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79634
Program Number: P333
Presentation Session: Poster (Non CME)
Presentation Type: Poster
