Not All Leaks Are Created Equal: a Comparison Between Leaks After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass

Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

When do leaks occur? An analysis of the metabolic and bariatric surgery accreditation and quality improvement program

BACKGROUND

Leak is a feared complication of bariatric surgeries. Time to presentation is important in their management. We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to evaluate the rate and timing of leaks.

OBJECTIVES

To determine when leaks present after bariatric surgery.

SETTING

MBSAQIP database.

METHODS

The MBSAQIP Participant Use Files (PUF) for the years 2015-2020 were evaluated. Outcomes of interest were "organ space infection" and "leak." We evaluated the time to presentation for these variables as well as patient characteristics, operative time, complication rates and 30-day outcomes.

RESULTS

There were 370,369 sleeve gastrectomies (SG) and 159,280 Roux-en-Y gastric bypasses (RYGB). We identified 598 (.16%) SG leaks with an average time to presentation of 13.2 ± 7.8 days. For RYGB, there were 520 leaks (.32%) with an average time to presentation of 9.5 ± 7.4 days. Both procedures had longer operative times for the patients with leak; RYGB was 115 minutes versus 131 minutes and SG was 67 minutes versus 77 minutes (both P < .01). SG and RYGB patients with a leak had a higher relative risk (RR) of grade 4 and 5 Clavien-Dindo complication rates. RR of mortality rates in SG patients with leak was 35.2 (confidence interval (CI): 20-61) and in RYGB with leak was 31.4 (CI: 19-50).

CONCLUSIONS

The length of time for SG leak presentation was more delayed than RYGB leak presentation. Surgeons should be vigilant for leaks for at least 3 weeks after surgery. Leaks increase the mortality rate and overall serious complications.

Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks

Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.

The Effect of Different Staple Sizes on Leak Pressure Among Patients Undergoing Sleeve Gastrectomy: a Pilot Study

Gastric leak after LSG is a devastating complication, reported in less than 1% of cases. Consensus is lacking regarding the best approach to construct the sleeve, staple sizes, and reinforcement methods on potential leak development. In this study, we have compared the leak pressure of two different staple sizes in the resected portion of the stomach, immediately after its removal. Fifteen patients were enrolled. Leak pressure of a vascular, small-size stapler was significantly higher than that of a medium-size one. All leaks appeared in the proximal third of the resected stomach. These results may have clinical implication. Since other factors may play a role in the risk for leaks following sleeve gastrectomy, a large, prospective clinical trial should be performed comparing the two staple sizes in laparoscopic sleeve gastrectomy.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry

BACKGROUND

Bleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding, including varying bougie size, line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and postoperative predictors of bleeding in patients undergoing SG.

OBJECTIVES

The purpose of this study was to examine predictors and outcomes associated with postoperative bleeding in patients undergoing LSG.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.

METHODS

We identified Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent LSG in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of bleeding in LSG patients. Our secondary outcomes of interest include characterizing overall complication rates in LSG patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ² tests for categorical data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of postoperative bleed.

RESULTS

A total of 175,353 patients underwent LSG from 2015 to 2016. The majority of patients were female (79.0%), with a mean age of 44.4 ± 12.0 years and a mean body mass index of 45.2 kg/m² ± standard deviation of 7.9 kg/m². A total of 1116 (.6%) patients had a postoperative bleed. Bleeding was associated with a mortality of 1.0% versus .1% among patients without bleeding. The mean operative time was 74.0 ± 36.6 minutes with a mean bougie size of 36.9 ± 2.9 Fr, and a mean pylorus distance of 4.80 ± 1.1 cm. Staple-line reinforcement was used in 67.8% of patients while 22.4% were oversewn. Bleeds were associated with a statistically significant increase in all complications, readmission, reoperation, and mortality rates at 30 days. The following statistically significant independent predictors of bleed after LSG were identified using multivariable logistic regression analysis: bougie size, age, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length. Staple-line reinforcement, staple-line oversewing, and higher body mass index were found to be protective for bleed after adjusting for confounders and interactions. An increase in pylorus distance did show a signal toward a protective effect; however, this was not statistically significant.

CONCLUSION

Bleeding after LSG is associated with increased complications, readmission and reoperation rates, and mortality at 30 days. Staple-line reinforcement techniques independently predict a lower risk of postoperative bleeding after LSG. Adoption of these techniques may therefore have an important role in reducing morbidity and mortality for patients who undergo LSG.