Leakage Post Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Morbid obesity shows a growing epidemiology in western world and LSG is becoming the most popular for the treatment of morbid obesity and  because of the permanent anatomical alternation following the bariatric operations, complications could occur any time during the course of a patient’s life.¹

For high-risk patients, LSG was recommended as the first step in a two-stage procedure aiming to reducing operative risk and comorbidities.²

Staple line leak one of the most common complications post LSG and this leak may be acute (early) or late (chronic) It occurs in up to 5% of patients following LSG ¹. Management depends on if there is intra-abdominal collection or no and the size of this collection. It also depends on extent of leak and the hemodynamic status of the patients.³ Gastric leakage (GL) post LSG has proven to be a disastrous complication leading to longer time of hospital stay and to use other modalities for rescue.⁴

GL is a catastrophic complication after bariatric surgery occurring in about 1-2% after LSG. This leak may be presented as peritonitis, abscess, fistula, sepsis and multi organ failure.⁵

In bariatric surgery the majority of post-operative death caused by staple line dehiscence and leak, so treatment of fistula and leak is critical especially after LSG as the staple line is long and the intraluminal pressure is elevated.⁶

Leak results in great health and economic burden to the patients and the health care facilities.⁷

Hemorrhage, narrowing of the tubular stomach, and gastric leakage are the most serious complications associated with stomach residue. A wide range of associated leak has been reported and ranged from 0.7-20%^{. 6}

Leakages that develop as a result of secondary ischemia appear 5 to 6 days after the operation. Leakages that develop due to technical issues are usually discovered within the first two days of the operation. Fever, epigastric pain, tachycardia, and leukocytosis are the most common symptoms in patients who develop leakages.⁸

LSG leaks can present with a wide range of clinical symptoms, from mild left shoulder pain to severe sepsis and multiple organ failure, depending on the severity of the leak itself.

The most serious associated complication following LSG is the gastric fistula because this type of fistula is difficult to be closed as compared to other types of fistula and because of the lack of standardization in the management of the fistula, especially the chronic fistula.⁹

It is necessary to have an increased level of suspicion in order to correctly identify a leak following an LSG. This treatment focuses on controlling sepsis and providing nutritional support. Each patient's care must be tailored to their specific needs.¹⁰.

PATIENTS AND METHODS

This is a retrospective study of patients who underwent LSG from 2017 to 2019 at Department of General Surgery at Al Zahraa University Hospital. 100 patients with morbid obesity, the mean BMI 45.6+5.5 kg/m2 underwent LSG

Laparoscopic sleeve gastrectomy with Anti-embolic precautions were taken and appropriate preoperative antibiotics were administered. Under general anesthesia with endotracheal intubation, the patient was in supine position. A pneumoperitoneum was achieved using closed technique with Veress needle. Five ports were used; three ports of size 12 mm were placed as an arc at 15-18 cm below the xiphoid and 3 cm to the left of the midline (optical port) and right and left midclavicular lines (working ports). A 5-mm trocar port was placed along the left subcostal margin (assistant port) another 5-mm port was placed in the epigastric region for liver retraction. The operating table was placed in reverse Trendelenburg position and the left lobe of the liver was retracted cephalic to expose the esophageal hiatus. A 30° angled laparoscope was used. Evacuation of gastric secretion and gas by nasogastric tube was done. The pylorus of the stomach was identified, and the greater curve of the stomach was elevated. Devascularization of the greater curvature of the stomach was done using the laparoscopic ultrasonic scalpel. A 35 Fr orogastric bougie was placed adjacent to the pylorus. The dissection was started 5-8 cm from the pylorus and proceeds to the angle of His. A 60 mm black or green cartridge was used for stapling at the beginning (proximal to pylorus). The second cartridge, black or green, was applied proximal to the angularis with care taken to avoid stenosis here. Stapling continued until 1-2 cm gastroesophageal junction by using a golden cartridge. The resected stomach was grasped by a laparoscopic grasper through one of the working port sites. Testing for leakage by injection of methylene through the orogastric bougie was achieved. Drain was placed routinely.

Routine post-operative gastrograffin on the second postoperative day was done for all patients. Also Clinical symptoms or laboratory investigations suggesting leak after LSG as discomfort, pain and signs as abdominal distension, fever tachypnea, tachycardia, increased WBCs, CRP, all were recorded in all patients.

All patients with leak patients were evaluated by CT abdomen and pelvis and started broad-spectrum antibiotics. Patients were closely observed for any clinical deterioration with no oral intake Fig. (1)

Fig. 1: Post sleeve CT scan with evidence of leak at the stable line in the middle portion

All data were collected demographic anthropometrics, comorbidities, operative and perioperative data, site of leak, time of presentation, method of detection and interval between detection and surgery.

Treatment of the patients with leak depends on hemodynamic state, presence of peritonitis, amount of collection and is the collection localized or diffuse. The decision between conservative and surgical exploration is made based on these circumstances.

In cases with suspected leaks abdomen and pelvis computed tomography with oral and intravenous contrast, gastrografin study, and upper endoscopy GI endoscopy. When there is localized collection or abscess in subphrenic space seen on CT it is treated by guided percutaneous drainage.

If the patient is hemodynamically stable and there is no generalized peritonitis gastrografin study with upper GI endoscopy is done to assess the size and the site of the leak and to assess if there is any stricture. If there is leak without stricture endoscopic stenting may be done. Follow up of body temperature, leukocyte count and drains output monitoring. If the patients' general condition improved, WBCs returned to normal, and the drain stopped draining, a CT scan was performed after one week to ensure there was no leak, and oral intake resumed. Patients were discharged after drain removal. Clinical examination and abdominal ultrasound are performed at 2 weeks, 4 weeks, and 12 weeks.

If the patient with leak is not stable we start with resuscitation and then laparoscopic exploration washing out and drainage. Feeding jejunostomy tube may be done at the same time. Postoperative observation of the amount and nature of drain output following surgery

According to Csendes et al., early, intermediate, and late leaks were classified as those that appeared 1 to 4, 5 to 9, and 10 or more days after surgery, respectively, after surgery.¹¹

RESULTS

100 patients were included in this study underwent for LSG 40 male and 60 females. The mean BMI was 45.7±5.5 kg/m2 (Table 1).

The mean operative time was 90 ± 15 minutes range (60-l5O minutes). The mean length of hospital stay was 4.5 ± 0.5 days range (10-l2days) (Table 2). There were no major intraoperative complications or death was recorded.

There were 6 cases of leak recorded. There were 5 females and 1 male, their BMI were 46-50 kg/m2 with mean operative time were 90 minutes range (70-160minutes). The time of presentation between surgery and readmission were between (4 days -one month). We record 1 case acute (early leak) presented on the 4^th day after LSG, 3 cases presented (5-9days) intermediate and the 2 cases referred were presented by late leak after 10 days -1 month. Patients were clinically presented with variation between abdominal pain with collection, tachycardia, fever and septic shock (Table 3&4).

One patient presented with delayed leak died from sepsis and respiratory distress. Diagnostic laparoscopy for the other case of delayed presentation with Inspection and irrigation of the abdomen. leak was confirmed with pneumatic test with conversion to Roux-en-y gastric bypass by creating 15-30 cc gastric pouch distal to the site of leak after that jejenum was transected with linear stapler at 40 cm after identification of ligament of treitz and the efferent limb was followed for 75 cm then jejunojejenstomy was done with linear stapler with putting wide pore drain tube near the site of leakage. The goal of drainage was placement of drains to create controlled fistula with use of antimicrobial agents, and nutrition consideration.

In one case Stent placement was used after IV sedation. Site of leak was found with endoscopic wire inserted into the stomach afterwards full covered stent with 240 mm length and 28 mm diameter with wire guide and finally stent is widely opened. CT guided percutaneous drainage and if no improvement after 48 hrs of conservative treatment (Table 5).

Table 1: Preoperative characters of the patients undergoing LSG.

Table 3: Signs and symptoms of patients with leak after sleeve gastrectomy

Table 4: Clinical presentation and laboratory investigations in patients with gastric leak

Table 5: intervention in each case with leak.