Abstract
Background
Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures.
Methods
Risk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence.
Results
Pathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage.
Conclusions
This review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40 Fr, EL:1, (2) begin the gastric transection 5–6 cm from the pylorus, EL:2–3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1 cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.
Similar content being viewed by others
References
Del Genio G, Tolone S, Limongelli P, Brusciano L, D’Alessandro A, Docimo G, Rossetti G, Silecchia G, Iannelli A, Del Genio A, Del Genio F (2014) Sleeve gastrectomy and development of “de novo” gastroesophageal reflux. Obes Surg 24(1):71–77
Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N (2015) Bariatric surgery worldwide 2013. Obes Surg 25(10):1822–1832
Gagner M, Buchwald JN (2014) Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review. Surg Obes Relat Dis 10(4):713–723
Peel AL, Taylor EW (1991) Proposed definitions for the audit of postoperative infection: a discussion paper. Surgical infection study group. Ann R Coll Surg Engl 73(6):385
Jurowich C, Thalheimer A, Seyfried F, Fein M, Bender G, Germer CT, Wichelmann C (2011) Gastric leakage after sleeve gastrectomy—clinical presentation and therapeutic options. Langenbeck's Arch Surg 396(7):981–987
Csendes A, Burdiles P, Burgos AM, Maluenda F, Diaz JC (2005) Conservative management of anastomotic leaks after 557 open gastric bypasses. Obes Surg 15(9):1252–1256
Rached AA, Basile M, El Masri H (2014) Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol 20(38):13904–13910
Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M (2004) The science of stapling and leaks. Obes Surg 14(10):1290–1298
Elariny H, González H, Wang B (2005) Tissue thickness of human stomach measured on excised gastric specimens from obese patients. Surg Technol Int 14:119–124
Huang R, Gagner M (2015) A thickness calibration device is needed to determine staple height and avoid leaks in laparoscopic sleeve gastrectomy. Obes Surg 25(12):2360–2367
Rosenthal RJ, Panel, I.S.G.E (2012) International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 8(1):8–19
Marczyk S, Tyco Healthcare Group Lp (2009) Powered surgical stapling device. U.S. Patent 7,637,409
Basso N, Casella G, Rizzello M, Abbatini F, Soricelli E, Alessandri G, Maglio C, Fantini A (2011) Laparoscopic sleeve gastrectomy as first stage or definitive intent in 300 consecutive cases. Surg Endosc 25(2):444–449
Bellanger DE, Greenway FL (2011) Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 21(2):146–150
Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, Matter I, Alfici R, Mahajna A, Waksman I, Shimonov M, Assalia A (2013) Gastric leaks after sleeve gastrectomy: a multicenter experience with 2834 patients. Surg Endosc 27(1):240–245
Saber AA, Azar N, Dekal M, Abdelbaki TN (2015) Computed tomographic scan mapping of gastric wall perfusion and clinical implications. Am J Surg 209(6):999–1006
Ruscio S, Abdelgawad M, Badiali D, Iorio O, Rizzello M, Cavallaro G, Severi C, Silecchia G (2016) Simple versus reinforced cruroplasty in patients submitted to concomitant laparoscopic sleeve gastrectomy: prospective evaluation in a bariatric center of excellence. Surg Endosc 30(6):2374–2381
Natoudi M, Theodorou D, Papalois A, Drymousis P, Alevizos L, Katsaragakis S, Zografos G, Leandros E, Menenakos E (2014) Does tissue ischemia actually contribute to leak after sleeve gastrectomy? An experimental study. Obes Surg 24(5):675–683
Baltasar A, Serra C, Pérez N, Bou R, Bengochea M, Ferri L (2005) Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg 15(8):1124–1128
Gagner M, Rogula T (2003) Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 13(4):649–654
Weiner RA, Weiner S, Pomhoff I, Jacobi C, Makarewicz W, Weigand G (2007) Laparoscopic sleeve gastrectomy—influence of sleeve size and resected gastric volume. Obes Surg 17(10):1297–1305
Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M (2013) Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 257(2):231–237
ElGeidie A, ElHemaly M, Hamdy E, El Sorogy M, Abdelgawad M, GadElHak N (2015) The effect of residual gastric antrum size on the outcome of laparoscopic sleeve gastrectomy: a prospective randomized trial. Surg Obes Relat Dis 11(5):997–1003
Obeidat F, Shanti H, Mismar A, Albsoul N, Al-Qudah M (2015) The magnitude of antral resection in laparoscopic sleeve gastrectomy and its relationship to excess weight loss. Obes Surg 25(10):1928–1932
Trastulli S, Desiderio J, Guarino S, Cirocchi R, Scalercio V, Noya G, Parisi A (2013) Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials. Surg Obes Relat Dis 9(5):816–829
Sarkhosh K, Birch DW, Sharma A, Karmali S (2013) Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon's guide. Can J Surg 56(5):347
Tønnesen H, Nielsen PR, Lauritzen JB, Møller AM (2009) Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth 102(3):297–306
Loke YK, Trivedi AN, Singh S (2008) Meta-analysis: gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs. Aliment Pharmacol Ther 27(1):31–40
Dapri G, Cadière GB, Himpens J (2010) Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg 20(4):462–467
Gentileschi P, Camperchioli I, D’Ugo S, Benavoli D, Gaspari AL (2012) Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial. Surg Endosc 26(9):2623–2629
Choi YY, Bae J, Hur KY, Choi D, Kim YJ (2012) Reinforcing the staple line during laparoscopic sleevegastrectomy: does it have advantages? A meta-analysis. Obes Surg 22(8):1206–1213
Knapps J, Ghanem M, Clements J, Merchant AM (2013) A systematic review of staple-line reinforcement in laparoscopic sleeve gastrectomy. JSLS 17(3):390–399
Glaysher M, Khan OA, Mabvuure NT, Wan A, Reddy M, Vasilikostas G (2013) Staple line reinforcement during laparoscopic sleeve gastrectomy: does it affect clinical outcomes? Int J Surg 11(4):286–289
D’Ugo S, Gentileschi P, Benavoli D, Cerci M, Gaspari A, Berta RD, Moretto C, Bellini R, Basso N, Casella G, Soricelli E (2014) Comparative use of different techniques for leak and bleeding prevention during laparoscopic sleeve gastrectomy: a multicenter study. Surg Obes Relat Dis 10(3):450–454
Shikora SA, Mahoney CB (2015) Clinical benefit of gastric staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis. Obes Surg 25(7):1133–1141
Rogula T, Khorgami Z, Bazan M, Mamolea C, Acquafresca P, El-Shazly O, Aminian A, Schauer P (2015) Comparison of reinforcement techniques using suture on staple-line in sleeve gastrectomy. Obes Surg 25(11):2219–2224
Albanopoulos K, Tsamis D, Arapaki A, Kleidi E, Zografos G, Leandros E (2015) Staple line reinforcement with stitch in laparoscopic sleeve gastrectomies. Is it useful or harmful? J Laparoendosc Adv Surg Tech 25(7):561–565
Albanopoulos K, Alevizos L, Flessas J, Menenakos E, Stamou KM, Papailiou J, Natoudi M, Zografos G, Leandros E (2012) Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing two different techniques. Preliminary results. Obes Surg 22(1):42–46
Iqbal A, Haider M, Stadlhuber RJ, Karu A, Corkill S, Filipi CJ (2008) A study of intragastric and intravesicular pressure changes during rest, coughing, weight lifting, retching, and vomiting. Surg Endosc 22(12):2571–2575
Yehoshua RT, Eidelman LA, Stein M, Fichman S, Mazor A, Chen J, Bernstine H, Singer P, Dickman R, Shikora SA, Rosenthal RJ (2008) Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg 18(9):1083–1088
Aydin MT, Aras O, Karip B, Memisoglu K (2015) Staple line reinforcement methods in laparoscopic sleeve gastrectomy: comparison of burst pressures and leaks. JSLS 19(3). doi:10.4293/JSLS.2015.00040
Shabbir A, Teh JL (2014) A new emerging procedure-sleeve gastrectomy. Essentials and controversies in bariatric surgery. InTech. Chapter 5, p 101–124
Sethi M, Zagzag J, Patel K, Magrath M, Somoza E, Parikh MS, Saunders JK, Ude-Welcome A, Schwack BF, Kurian MS, Fielding GA (2015) Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy. Surg Endosc 30(3):883–891
Zacharoulis D, Sioka E, Papamargaritis D, Lazoura O, Rountas C, Zachari E, Tzovaras G (2012) Influence of the learning curve on safety and efficiency of laparoscopic sleeve gastrectomy. Obes Surg 22(3):411–415
Rebibo L, Blot C, Verhaeghe P, Cosse C, Dhahri A, Regimbeau JM (2014) Effect of perioperative management on short-term outcomes after sleeve gastrectomy: a 600-patient single-center cohort study. Surg Obes Relat Dis 10(5):853–858
Noel P, Nedelcu M, Gagner M (2015) Impact of the surgical experience on leak rate after laparoscopic sleeve gastrectomy. Obes Surg:1–6. doi:10.1007/s11695-015-2003-1
Benedix F, Benedix DD, Knoll C, Weiner R, Bruns C, Manger T, Stroh C, Obesity Surgery Working Group (2014) Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity? Obes Surg 24(10):1610–1616
Abdelgawad M, De Angelis F, Iossa A, Rizzello M, Cavallaro G, Silecchia G (2016) Management of complications and outcomes after revisional bariatric surgery: 3-year experience at a bariatric center of excellence. Obes Surg:1–6. doi:10.1007/s11695-016-2071-x
Silecchia G, Rizzello M, De Angelis F, Raparelli L, Greco F, Perrotta N, Lerose MA, Campanile FC (2014) Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a “2-step approach”: a multicenter study. Surg Obes Relat Dis 10(4):626–631
Dang JT, Switzer NJ, Wu J, Gill RS, Shi X, Thereaux J, Birch DW, de Gara C, Karmali S (2016) Gastric band removal in revisional bariatric surgery, one-step versus two-step: a systematic review and meta-analysis. Obes Surg 26(4):866–873. doi:10.1007/s11695-016-2082-7
Silecchia G, De Angelis F, Rizzello M, Albanese A, Longo F, Foletto M (2015) Residual fundus or neofundus after laparoscopic sleeve gastrectomy: is fundectomy safe and effective as revision surgery? Surg Endosc 29(10):2899–2903
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
This article does not contain any studies with human participants or animals.
Additional information
Angelo Iossa and Mohamed Abdelgawad contributed equally to this work.
Rights and permissions
About this article
Cite this article
Iossa, A., Abdelgawad, M., Watkins, B.M. et al. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbecks Arch Surg 401, 757–766 (2016). https://doi.org/10.1007/s00423-016-1464-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00423-016-1464-6