The Evolution of Treatment for Laparoscopic Sleeve Gastrectomy Staple Line Leak: A Single Institution’s Experience.

Jill L Gorsuch, DO, MPH, David Podkameni, MD, Albert Y Chen, MD, Emil T Graf, MD, Flavia Soto, MD. Banner Gateway

Introduction

Laparoscopic sleeve gastrectomy (LSG) has become a standard procedure in the bariatric surgeons’ armamentarium for obesity surgery. Recognized as a standalone procedure, there has been a recent increase in the number of procedures performed. As the number of cases increase, so do the number of complications. Staple line leak can be a devastating morbidity, which can consume health care resources as well as be detrimental to the patient. Just as the technique for the LSG has evolved, so have the treatment methods for the management of post-operative leak. According to the International sleeve gastrectomy expert panel consensus statement from Rosenthal in 2012, initial intervention included surgical exploration, drainage, esophageal stenting and possible conversion to Roux-en-Y bypass. Over the scope endoscopic endoclip is a new technique not part of the algorithm that is becoming more widely used with positive results. This is a case series of interventions for successful treatment of staple line leak status post LSG at a single Center of Excellence institution.

Methods and Procedures

This is a case series for a single institution. Four bariatric surgeons’ cases were reviewed from 2012-2014 using office records, and hospital medical records. Only laparoscopic sleeve gastrectomy cases were included in this review. The complications were encountered at both the home institution, as well as in patients transferred from out of state or out of the country.

Results

During the study period from 2012-2014 there were 490 LSG performed. At the institution, a total of 7 leaks (1.4%) were documented at 30-day follow-up, and 1 (0.2%) documented greater than 30 days. One leak was transferred from an outside hospital, and had LSG performed outside of the country. Of the 9 leaks over the 2-year time period, two were successfully treated by conservative management including interventional radiology drainage, intravenous antibiotics and parenteral or enteral nutritional support. The average length of treatment to resolution was 29 (22-35) days. One patient has had conservative and endoscopic management with complete resolution in 30 days with IR drainage and EGD with over the scope endoclip. Six of the patients had exploratory laparoscopy with washout and drain placement. Within this population 3 of the 6 patients also had post procedure endoscopy with over the scope endoclip. One patient had an endoscopic stent. One patient had fibrin glue endoscopically injected into the fistula Five of the 6 patients had resolution with an average of 50 (13-118) days. One patient is still receiving treatment.

Conclusion

LSG leak is a devastating complication with treatment options that are continually evolving. The improving technology has allowed for more minimally invasive approaches including esophageal stenting and endoscopic clipping allowing for less morbidity during the intervention. Our institution has utilized these new techniques in our treatment regimen for successful closure of LSG leaks.