Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients

Background Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. Methods Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the L...

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Vydané v:	Surgical endoscopy Ročník 27; číslo 1; s. 240 - 245
Hlavní autori:	Sakran, Nasser, Goitein, David, Raziel, Asnat, Keidar, Andrei, Beglaibter, Nahum, Grinbaum, Ronit, Matter, Ibrahim, Alfici, Ricardo, Mahajna, Ahmad, Waksman, Igor, Shimonov, Mordechai, Assalia, Ahmad
Médium:	Journal Article
Jazyk:	English
Vydavateľské údaje:	New York Springer-Verlag 01.01.2013 Springer Nature B.V
Predmet:	Abdominal Surgery Adult Case-Control Studies Conversion to Open Surgery - statistics & numerical data Female Gastrectomy - adverse effects Gastroenterology Gastrointestinal surgery Gastroplasty - adverse effects Gynecology Hepatology Humans Intraoperative Complications - etiology Laparoscopy Laparoscopy - adverse effects Male Medicine Medicine & Public Health Morbidity Mortality Obesity Obesity, Morbid - surgery Patients Proctology Reoperation Retrospective Studies Statistical analysis Surgery Surgical Wound Dehiscence - etiology Surgical Wound Dehiscence - surgery Treatment Outcome Weight control Tel Aviv Israel Israel Morbid obesity Gastric leak Laparoscopic sleeve gastrectomy Mortality Morbidity
ISSN:	0930-2794, 1432-2218, 1432-2218
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Abstract	Background Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. Methods Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. Results Among the 2,834 patients who underwent LSG, 44 (1.5 %) with gastric leaks were identified. Of these 44 patients, 30 (68 %) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m 2 . Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3 %) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0–2 days) in nine cases (20 %), intermediately (3–14 days) in 32 cases (73 %), and late (>14 days) in three cases (7 %). For 38 patients (86 %), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84 %), 11 (50 %), and 9 (60 %) of these patients. Reoperation was performed for 27 of the patients (61 %). Other treatment methods included percutaneous drainage ( n = 28, 63.6 %), endoscopic placement of stents ( n = 11, 25 %), clips ( n = 1, 2.3 %), and fibrin glue ( n = 1, 2.3 %). In 33 of the patients (75 %), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2–270 days), and the overall leak-related mortality rate was 0.14 % (4/2,834). Conclusion Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.
AbstractList	Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. Among the 2,834 patients who underwent LSG, 44 (1.5 %) with gastric leaks were identified. Of these 44 patients, 30 (68 %) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m^sup 2^. Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3 %) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20 %), intermediately (3-14 days) in 32 cases (73 %), and late (>14 days) in three cases (7 %). For 38 patients (86 %), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84 %), 11 (50 %), and 9 (60 %) of these patients. Reoperation was performed for 27 of the patients (61 %). Other treatment methods included percutaneous drainage (n = 28, 63.6 %), endoscopic placement of stents (n = 11, 25 %), clips (n = 1, 2.3 %), and fibrin glue (n = 1, 2.3 %). In 33 of the patients (75 %), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14 % (4/2,834). Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.[PUBLICATION ABSTRACT] Background Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. Methods Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. Results Among the 2,834 patients who underwent LSG, 44 (1.5 %) with gastric leaks were identified. Of these 44 patients, 30 (68 %) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m 2 . Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3 %) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0–2 days) in nine cases (20 %), intermediately (3–14 days) in 32 cases (73 %), and late (>14 days) in three cases (7 %). For 38 patients (86 %), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84 %), 11 (50 %), and 9 (60 %) of these patients. Reoperation was performed for 27 of the patients (61 %). Other treatment methods included percutaneous drainage ( n = 28, 63.6 %), endoscopic placement of stents ( n = 11, 25 %), clips ( n = 1, 2.3 %), and fibrin glue ( n = 1, 2.3 %). In 33 of the patients (75 %), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2–270 days), and the overall leak-related mortality rate was 0.14 % (4/2,834). Conclusion Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed. Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak.BACKGROUNDLaparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak.Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters.METHODSEight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters.Among the 2,834 patients who underwent LSG, 44 (1.5%) with gastric leaks were identified. Of these 44 patients, 30 (68%) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m(2). Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3%) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20%), intermediately (3-14 days) in 32 cases (73%), and late (>14 days) in three cases (7%). For 38 patients (86%), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84%), 11 (50%), and 9 (60%) of these patients. Reoperation was performed for 27 of the patients (61%). Other treatment methods included percutaneous drainage (n = 28, 63.6%), endoscopic placement of stents (n = 11, 25%), clips (n = 1, 2.3%), and fibrin glue (n = 1, 2.3%). In 33 of the patients (75%), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14% (4/2,834).RESULTSAmong the 2,834 patients who underwent LSG, 44 (1.5%) with gastric leaks were identified. Of these 44 patients, 30 (68%) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m(2). Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3%) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20%), intermediately (3-14 days) in 32 cases (73%), and late (>14 days) in three cases (7%). For 38 patients (86%), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84%), 11 (50%), and 9 (60%) of these patients. Reoperation was performed for 27 of the patients (61%). Other treatment methods included percutaneous drainage (n = 28, 63.6%), endoscopic placement of stents (n = 11, 25%), clips (n = 1, 2.3%), and fibrin glue (n = 1, 2.3%). In 33 of the patients (75%), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14% (4/2,834).Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.CONCLUSIONGastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed. Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. Among the 2,834 patients who underwent LSG, 44 (1.5%) with gastric leaks were identified. Of these 44 patients, 30 (68%) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m(2). Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3%) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20%), intermediately (3-14 days) in 32 cases (73%), and late (>14 days) in three cases (7%). For 38 patients (86%), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84%), 11 (50%), and 9 (60%) of these patients. Reoperation was performed for 27 of the patients (61%). Other treatment methods included percutaneous drainage (n = 28, 63.6%), endoscopic placement of stents (n = 11, 25%), clips (n = 1, 2.3%), and fibrin glue (n = 1, 2.3%). In 33 of the patients (75%), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14% (4/2,834). Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.
Author	Shimonov, Mordechai Assalia, Ahmad Waksman, Igor Sakran, Nasser Keidar, Andrei Mahajna, Ahmad Beglaibter, Nahum Raziel, Asnat Grinbaum, Ronit Matter, Ibrahim Alfici, Ricardo Goitein, David
Author_xml	– sequence: 1 givenname: Nasser surname: Sakran fullname: Sakran, Nasser email: sakranas@yahoo.com, nassers@hy.health.gov.il organization: Department of Surgery, Hillel Yaffe Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology – sequence: 2 givenname: David surname: Goitein fullname: Goitein, David organization: Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University – sequence: 3 givenname: Asnat surname: Raziel fullname: Raziel, Asnat organization: Assia Medical Group, Assuta Hospital – sequence: 4 givenname: Andrei surname: Keidar fullname: Keidar, Andrei organization: Hadassah-Hebrew University Medical Center – sequence: 5 givenname: Nahum surname: Beglaibter fullname: Beglaibter, Nahum organization: Hadassah-Hebrew University Medical Center – sequence: 6 givenname: Ronit surname: Grinbaum fullname: Grinbaum, Ronit organization: Hadassah-Hebrew University Medical Center – sequence: 7 givenname: Ibrahim surname: Matter fullname: Matter, Ibrahim organization: Bnai Zion Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology – sequence: 8 givenname: Ricardo surname: Alfici fullname: Alfici, Ricardo organization: Department of Surgery, Hillel Yaffe Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology – sequence: 9 givenname: Ahmad surname: Mahajna fullname: Mahajna, Ahmad organization: Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology – sequence: 10 givenname: Igor surname: Waksman fullname: Waksman, Igor organization: Ziv Medical Center – sequence: 11 givenname: Mordechai surname: Shimonov fullname: Shimonov, Mordechai organization: Wolfson Medical Center, Sackler School of Medicine, Tel Aviv University – sequence: 12 givenname: Ahmad surname: Assalia fullname: Assalia, Ahmad organization: Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology
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Keywords	Morbid obesity Gastric leak Laparoscopic sleeve gastrectomy Mortality Morbidity
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Snippet	Background Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple... Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak.... Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line...
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SubjectTerms	Abdominal Surgery Adult Case-Control Studies Conversion to Open Surgery - statistics & numerical data Female Gastrectomy - adverse effects Gastroenterology Gastrointestinal surgery Gastroplasty - adverse effects Gynecology Hepatology Humans Intraoperative Complications - etiology Laparoscopy Laparoscopy - adverse effects Male Medicine Medicine & Public Health Morbidity Mortality Obesity Obesity, Morbid - surgery Patients Proctology Reoperation Retrospective Studies Statistical analysis Surgery Surgical Wound Dehiscence - etiology Surgical Wound Dehiscence - surgery Treatment Outcome Weight control
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Title	Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients
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