Is There a Place for Pigtail Drains in the Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy?

Abstract

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. "Treatment success" was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1-11) per patient, of covered SEMS was three (range, 1-8), and of pigtail drains was three (range, 1-4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n = 1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity-mortality than covered SEMS.

Full text

CLINICAL REPORT
Is There a Place for Pigtail Drains in the Management
of Gastric Leaks After Laparoscopic Sleeve Gastrectomy?
A. Pequignot &D. Fuks &P. Verhaeghe &A. Dhahri &
O. Brehant &E. Bartoli &R. Delcenserie &T. Yzet &
J.-M. Regimbeau
#Springer Science+Business Media, LLC 2012
Abstract Laparoscopic sleeve gastrectomy (LSG) has a
specific morbidity profile in which gastric leak (GL) is the
main complication. With a view to defining a standardized
protocol for GL management, the present retrospective
study sought to describe the clinical patterns of post-LSG
GL and treatment of the latter in our university medical
center. From July 2004 to December 2010, 25 patients were
included. GL was described in terms of clinical presentation,
time to onset, and location in the staple line. Treatment of
GL with pharmacologic, radiologic, endoscopic, and/or
surgical procedures was always validated by a multidisci-
plinary care team. “Treatment success”was defined as the
absence of contrast agent leakage on CT and endoscopy
after removal of covered metallic stent or pigtail drains.
Systemic inflammation and peritonitis were the main signs
for early-onset GL (56%), whereas pulmonary symptoms
and intra-abdominal abscesses revealed delayed-onset GL
(44%). Surgery was always performed for early-onset GL.
In the total study population, the median number of endo-
scopic procedures was five (range, 1–11) per patient, of
covered SEMS was three (range, 1–8), and of pigtail drains
was three (range, 1–4). Nine (36%) patients presented
endoscopic-related complications. Four (16%) patients with
treatment failure underwent radical surgery. The mortality
rate was 4% (n01). The management of post-LSG GL is
challenging. Surgery was always performed for early-onset
GL, whereas treatment of delayed-onset GL was based on
endoscopy. Pigtail drains required fewer procedures per
patient, were better tolerated, and had lower morbidity–
mortality than covered SEMS.
Keywords Bariatric surgery .Sleeve gastrectomy .
Gastric leakage .Conservative management
Abbreviations
LSG Laparoscopic sleeve gastrectomy
BMI Body mass index
GL Gastric leak
GE Gastrografin esophagography
POD Post-operative day
SEMS Self-expandable metallic stent
LABG Laparoscopic adjustable gastric band
LGBP Laparoscopic gastric bypass
EWL Excess weight loss
A. Pequignot :D. Fuks :P. Verhaeghe :A. Dhahri :O. Brehant :
J.-M. Regimbeau (*)
Department of Digestive and Metabolic Surgery,
Amiens University Medical Center and
Jules Verne University of Picardie,
North Hospital, Place Victor Pauchet,
80054 Amiens Cedex 01, France
e-mail: regimbeau.jean-marc@chu-amiens.fr
E. Bartoli :R. Delcenserie
Department of Clinical and Endoscopic Gastroenterology,
Amiens University Medical Center and
Jules Verne University of Picardie,
North Hospital, Place Victor Pauchet,
80054 Amiens Cedex 01, France
T. Yzet
Department of Radiology,
Amiens University Medical Center and
Jules Verne University of Picardie,
North Hospital, Place Victor Pauchet,
80054 Amiens Cedex 01, France
P. Verhaeghe
Department of Digestive Surgery, CHU Nord,
Place Victor Pauchet,
80054 Amiens Cedex 01, France
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DOI 10.1007/s11695-012-0597-0

Introduction
In many industrialized countries, the prevalence of morbid
obesity has increased significantly over the last 10 years [1].
The incidence of co-morbidities (such as diabetes mellitus,
hypertension, metabolic syndrome, vascular disease, and joint
disease) has also increased in this population. Bariatric surgery
has been validated for the treatment of patients with severe
obesity (i.e., a body mass index (BMI) of between 35 and
40 kg/m²) and co-morbidities and patients with extreme obesity
(i.e., a BMI over 40 kg/m²) [1,2]. Bariatric surgery not only
reduces the co-morbidities associated with obesity but also
increases overall survival in this population of patients [3–5].
Bariatric surgery includes restrictive procedures (such as
laparoscopic adjustable gastric band (LABG) and laparo-
scopic sleeve gastrectomy (LSG)) and malabsorptive proce-
dures (laparoscopic gastric bypass, LGBP). Laparoscopic
sleeve gastrectomy is increasingly acknowledged to be a
valid, stand-alone procedure for the surgical management
of morbid obesity [6–8] and, on average, enables patients to
lose between 60% and 70% of their excess weight in 3 years
following surgery [9,10]. However, LSG has a specific
significant morbidity pattern in which gastric staple line leak
is the main complication. Although gastric leak (GL) after
LSG occurs in less than 5% of patients, it significantly
increases the hospital length of stay and can be life-
threatening [7]. The post-operative diagnosis of this entity is
often difficult in obese patients. Moreover, the managementof
post-operative GL is difficult and not yet consensual.
With a view to defining a standardized protocol for GL
management, the present retrospective study sought to
describe the clinical patterns of post-LSG GL and treatment
of the latter in our university medical center.
Methods
Population
From July 2004 to December 2010, 497 morbidly obese
patients (406 women (82%) and 91 men (18%)) underwent
LSG in our institution. The median BMI was 47 kg/m
2
(range, 30 to 74 kg/m
2
) and the median patient age was 41
(range, 18 to 65). Sixteen of the 497 patients (3%) devel-
oped post-operative GL. Nine other patients were referred to
our hospital with a diagnosis of post-LSG GL. Hence, the
final study population comprised 25 patients.
Surgical Procedures for LSG in Our Institution
Pre-operative Management According to the French nation-
al guidelines [1], the indication of bariatric surgery was vali-
dated in a multidisciplinary care team meeting. Each patient
underwent surgical consultations, a nutritional and dietary
analysis, and respiratory, endocrine and psychological
assessments. Hiatus hernia and Helicobacter pylori infec-
tions were screened for with gastric endoscopy.
Intra-operative Management Our protocol has already been
described elsewhere [11,12]. LSG was always performed by
using a laparoscopic technique. Division of the gastric greater
curvature's vascular supply started at 6 cm from the pylorus
and proceeded upwards to the angle of His by using the
LigaSure™Vessel Sealing System (Covidien, Norwalk, CT,
USA). The diameter of the gastric tube was at least 34 Fr.
Staple line reinforcement was not always performed. After
stomach clamping, methylene blue test was always performed
to screen for staple line leak. Between 2004 and 2007, we
always placed an abdominal drain close to the staple line in
order to screen for GL at POD 1 with oral methylene blue test.
From 2008 to date, drainage was only used in the event of
intra-operative bleeding or a positive intra-operative methy-
lene blue test. The patient was taken to a recovery room and
the nasogastric tube was removed upon awakening.
Post-operative Management We monitored clinical symp-
toms (e.g., abdominal pain, abdominal distension, cough,
and peritoneal syndrome) and general signs (e.g., fever,
tachycardia, dyspnea, and tachypnea) in all patients. Gastro-
grafin esophagography (GE) was performed in all patients on
POD 1. While standing, the patient swallowed 20 ml of
gastrografin and six different radiographs were taken. The
characteristics of the tubulized stomach (i.e., dimensions,
emptying, and the presence or absence of leak or stricture)
were then evaluated. As mentioned above, oral methylene
blue test on POD 1 was used during the period 2004–2007 to
diagnose post-operative GL. Since 2008, this test was not
used anymore. If post-operative GL was clinically suspected,
oral contrast computed tomography (CT) scan was always
performed. Findings suggestive of GL were extravasation of
contrast agent through the wall of the gastric sleeve, accu-
mulation adjacent to the sleeve, free intra-abdominal liquid,
residual contrast agent in the drainage tube, and free intra-
abdominal gas. Eating was authorized on POD 1 if these
tests failed to evidence GL. In most cases, the patient was
discharged on POD 2 or 3.
Definition of Terms and Classification of GL
Gastric leak was described according to the modified UK
Surgical Infection Study Group classification [13,14]in
terms of its clinical presentation, time to onset, and location
in the staple line. The clinical presentation was described in
terms of systemic signs of inflammation (tachycardia >100/
min, hyperthermia >38°C), peritonitis (diffuse abdominal
tenderness), pulmonary symptoms (cough and expectoration),
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and intra-abdominal abscess (localized abdominal tender-
ness). The post-LSG time to onset differentiated between
early-onset GL (from POD 1 to POD 7) and delayed-onset
GL (≥POD 8). Identification of the GL site distinguished
between leakage from the upper third of the staple line and
leakage from the lower third. Endoscopic visualization of the
gastric orifice was not always required.
Treatment Options for GL
Treatment of GL was always validated by a multidisciplinary
care team dedicated to the management of bariatric complica-
tions. All 25 patients received one or more medications
(including proton pump inhibitors, appropriate antibiotics,
somatostatin analogs) and either exclusively parenteral nutri-
tion or enteral nutrition via a feeding jejunostomy. Interven-
tional options included surgery (laparoscopy or laparotomy
with abdominal washout, abdominal drainage close to the
staple line, and a feeding jejunostomy), endoscopic proce-
dures (covered with antireflux valve self-expandable metallic
stents (SEMS), clips, biological glue (Histoacryl®), and
pigtail drains), and radiological procedures (percutaneous
drainage). Surgery was always performed for early-onset GL
and considered in delayed-onset GL in patients with signs of
peritonitis or hemodynamic instability only.
We deliberately distinguished between two endoscopic
treatment periods. From 2004 to 2007, treatment was essen-
tially based on intra-operative and post-operative placement
of covered SEMS, together with clips and Histoacryl®.
From 2008 to date, we abandoned intra-operative endoscopic
procedures and started to use pigtail drains (instead of SEMS)
to drain the GL inside the stomach.
The SEMS used were covered with antireflux valve
self-expandable metallic stent HANAROSTENT® (LIFE
PARTNERS EUROPE 161 avenue Galliéni-93170 Bagnolet,
France). Stents were placed in front of the staple line
orifice during intra- or post-operative endoscopy with
fluoroscopy. An abdominal X-ray was taken weekly in
order to check the SEMS position. The covered SEMS
was always left in place for 4 weeks (its removal after
this delay was difficult). Pump inhibitors and anti-nausea
agent were always administered in order to avoid hiccups
or gastric ulceration.
Pigtail drains (Zimmon® Biliary Stent from Cook Ireland
Ltd, Limerick, Ireland) were placed through the staple line
orifice by endoscopy. In some cases, a nasobiliary drain was
used to stimulate resorption of the collected fluid. Pigtail
drains were removed 6 weeks after insertion. External drain-
age (inserted during radiological or surgical procedures)
always involved regular endoscopic checks (the end of the
stent is often located in the GL orifice, leading to a wall
healing disorder) and early removal after pigtail drain inser-
tion (regardless of the outflow, if the patient's clinical and
biochemical status was satisfactory) in order to avoid the
development of an external fistula.
Endpoints and Study Design
We performed a retrospective analysis of a dedicated, pro-
spective database of bariatric surgery patients. The primary
endpoint was to define the patterns of GL after LSG and the
overall management of this condition. Secondary endpoints
included a comparison of the two GL treatment periods
(2004–2007 versus 2008–2011) and morbidity–mortality.
“Treatment success”was defined as absence of contrast
agent leakage in CT and endoscopic evaluations after per-
manent, covered SEMS, or pigtail drains had been removed.
In contrast, “treatment failure”was defined as the need for
radical surgery for persistent GL (total gastrectomy or
Roux-en-Y gastroenterostomy at the site of GL) [15].
Statistical Analysis
The patients’baseline characteristics are expressed as the
mean value ± standard deviation (SD) and the median
(interquartile range) for continuous data and as a frequency
for categorical data. Our univariate analysis used Student's
T-test for quantitative variables. Mann–Whitney U-test was
used for non-parametric variables. The threshold for statis-
tical significance was set to p<0.05. All statistical tests were
performed with SPSS software (version 15.0 for Windows,
SPSS Inc., Chicago, IL, USA).
Results
The Occurrence of LSG Without GL
Of the 497 patients who underwent LSG in our institution,
481 (97%) did not experience post-operative GL. For these
patients without post-operative GL, the median operating
time was 70 min (range, 45–120) and the median length of
stay was 2.3 days (range, 2–3).
General Features of Post-operative GL
The study synopsis is presented in Fig. 1. Twenty-five
patients developed GL (4 men and 21 women (84%); me-
dian age was 41 years (range, 23-58)). The median preop-
erative BMI was 48.5 (range, 36-66). In clinical terms, eight
patients (32%) had systemic signs of inflammation, seven
(28%) had peritonitis, two (8%) had pulmonary symptoms,
and eight (32%) had an intra-abdominal abscess. The medi-
an time to onset of GL was 6 days (range, 1–248). Fourteen
(56%) patients had early-onset GL (median time to onset,
3 days; range, 1–6) (Fig. 2) and 11 (44%) had delayed-onset
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GL (median time to onset, 21 days; range, 8-248) (Fig. 3).
The GL was located within the upper third of the staple line
near the esophago-gastric junction in 19 patients (76%) and
within the lower third in six patients (24%). Overall, the
median number of endoscopic procedures was five per
patient (range, 1–11). The median number of covered SEMS
used was three per patient (range, 1–8) and the median
number of pigtail drains used was two per patient (range,
1–4). The median number of surgical procedures was one
(range, 0–5). Four (16%) patients with treatment failure
underwent radical surgery. The mortality rate was 4%
(n01). The median length of stay was 114 days (range, 7–257).
Treatment of Early-Onset GL
Fourteen (56%) patients had early GL (median delay POD
3; range, 1–6) (Table 1). Seven patients (50%) had initial
systemic signs of inflammation and the seven others had
peritonitis. None of the patients with early-onset GL had
pulmonary symptoms or an abscess. Once the diagnosis of
early-onset GL has been confirmed, surgery was performed
within 24 h in all cases. The median time interval between
LSG and the first re-operation was 4 days (range, 2–7). The
re-operations included gastric suture (n05), washout (n0
14), abdominal drainage (n014), and feeding jejunostomy
(n011). Identification of the site of GL was facilitated in
eight patients (57%) by intra-operative gastroscopy. Of the
latter, six (75%) received a covered SEMS during the same
surgical session. During follow-up, two patients (14%) re-
quired a second re-operation, two patients (14%) underwent
three re-operations, and one patient (7%) required four re-
operations. After the initial re-operation, the endoscopic
procedure included a covered SEMS in ten patients (71%).
One of the latter patients also received pigtail drains. The
median number of covered SEMS used was two (range, 1–
7) per patient and seven (50%) patients had ≥2covered
SEMS inserted during the same endoscopic procedure.
The median number of endoscopic procedures per patient
was four (range, 1–9). Percutaneous drainage was per-
formed in two patients (14%). Conservative treatment was
successful in 12 (86%) patients after a median follow-up
period of 114 days (range, 7–208).
Treatment of Delayed-Onset GL
As mentioned above, 11 patients (44%) had delayed-onset
GL (median delay POD 21; range, 8–248) (Table 1). One
(9%) patient had initial systemic signs of inflammation, two
(18%) had pulmonary symptoms, and the eight remaining
patients (73%) had an abscess. None of the patients under-
went surgery immediately after the diagnosis of delayed-
onset GL. During the follow-up period, six patients (55%)
required re-operation.
From 2004 to 2007, a covered SEMS was inserted in
three patients (27%); the median number of covered SEMS
inserted per patient was four (range, 3–8) and the median
number of endoscopy procedures per patient was 5.5 (range,
1–11). Two patients required radical surgery. Since 2008,
the median number of covered SEMS inserted per patient
was two (range, 1–4). All patients with intra-abdominal
abscesses were treated with pigtail drains (median number,
two (range, 2–4)). The pigtail drains were removed during
GL after LSG n=25
Early-onset GL
Treatment failure
2004-2007 2008-2010
Delayed-onset GL
Treatment success
n=2
n=12
n=2
n=2 n=7
n=4 n=7
Fig. 1 Synopsis
Fig. 2 Early-onset gastric leak.
aGastrografin esophagography
with gastric leak on the
upper third of the staple line
(white arrow). bAbdominal
X-ray showing two covered,
self-expandable metallic stents
inserted in order to bypass the
gastric leak (black arrow)
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endoscopy after a median time interval of 45 days (range,
31–61). None of the patients required radical surgery, none
died, and none required percutaneous drainage. Conserva-
tive treatment was successful in nine patients (82%) and the
median time to resolution of GL healing was significantly
shorter in patients treated with pigtail drains (62 vs. 129 days,
p00.001). Patients treated with pigtail drains underwent a
significantly lower median number of endoscopic procedures
(3 vs. 5.5, p00.04).
Complications of Endoscopic Procedures
Nine (36%) patients presented endoscopy-related complica-
tions (Fig. 4). Covered SEMS was responsible for five
mucosal ulcerations (56%) (including two with hemorrhage)
and four stent migrations (44%). In all cases, these compli-
cations were treated by removal of the covered SEMS.
Pigtail drains were responsible for one case of peritonitis
(9%) immediately after insertion and one case of wall
incarceration (9%).
Details of Treatment Failures
Conservative treatment failed for four patients (two (50%)
with early-onset GL and two with delayed-onset GL)
(Table 2). Radical surgery was considered after a median
of 153 days post-LSG. Patient #1 was a 56-year-old woman
who underwent LSG after LABG failure. Seventy-nine days
after LSG, a Roux-en-Y gastrojejunostomy was performed.
The post-operative course was uneventful and the patient
was discharged on POD 99. Patient #2 was a 33-year-old
woman who underwent resection of the left lower pulmo-
nary lobe (via a thoracotomy) and underwent Roux-en-Y
gastrojejunostomy on POD 248 for a bronchogastric fistula.
Fig. 3 Delayed-onset gastric
leak. aA contrast-enhanced
abdominal CT scan showing
fluid collection adjacent to the
staple line bulging in the
stomach (white arrow). b
Endoscopy showing fluid
collection bulging in the stomach
(black arrow). cA photograph
of the pigtail drain prior to
implantation. dAbdominal
X-ray showing two pigtail drains
after the endoscopic procedure
Table 1 Details of the treatment
of GL as a function of its time
to onset
SEMS self-expandable metallic
stent
a
During follow-up in one
patient, with two pigtail drains
Early-onset GL Delayed-onset GL
From 2004 to 2007 2008–2011
Number of patients, n(%) 14 4 7
Number of surgical procedures (median) 1 (1–5) 1.5 (0–3) 0 (0–2)
Number of patients with intra-operative
endoscopic procedures
80 0
Covered SEMS 1.5 (1–2) 1 (1–2) 0 (0–0)
Post-operative endoscopic procedures (median) 4 (1–9) 5.5 (1–11) 3 (1–5)
Covered SEMS 2 (1–7) 4 (3–8) 2 (1–4)
Pigtail drains 2
a
0(0–0) 2 (2–4)
Radical surgery 2 2 0
Median time to healing (days) 114 (7–208) 129 (59–257) 62 (27–241)
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The post-operative course included anastomotic dehiscence
and the patient was discharged from hospital on POD 350.
Patient #3 was a 23-year-old woman [16] who underwent
total gastrectomy, reconstruction of the diaphragm (using an
extended latissimus dorsi flap), and a pulmonary lobectomy
on POD 153 for persistent bronchogastric fistula. Patient #4
was a 53-year-old woman who received a covered SEMS on
POD 3 for early-onset GL after LSG. On POD 4, the patient
developed acute hematemesis. A contrast-enhanced CT scan
revealed a left gastric artery aneurysm. The covered SEMS
was removed and the aneurysm was unsuccessfully treated
with selective embolization. Emergency surgery included
total gastrectomy with a Roux-en-Y esophagojejunostomy.
The post-operative course was marked by acute, extended,
mesenteric ischemia, and extensive small bowel resection.
The patient died of multi-organ failure in the intensive care
unit on POD 172.
Bariatric Results
Of the 24 surviving patients with GL, the median excess
weight loss 1 year after GL closure was 50.5% (range,
18–117).
Discussion
Our large, single-center series showed that post-LSG GL is
rare but requires lengthy, complex management. To the best of
our knowledge, few literature series have specifically sought
to standardize the management of GL. Post-operative GL
affected 3% of our LSG patients. About half of the cases of
GL were diagnosed before POD 7. Early- and delayed-onset
GL each required specific treatments, including pharmaco-
logic, endoscopic, radiological, and surgical procedures. These
Fig. 4 Endoscopy with visualization of the gastric leak orifice (white
arrow) and the gastric tract after removal of the covered self-
expandable metallic stent (endoscopic treatment for early-onset gastric
leak). The gastric leak orifice was larger than the digestive tract
Table 2 Details of the four patients who required radical surgery
Patient Age (years) Gender BMI Time to
diagnosis
Clinical
presentation
Surgery Intra-operative
endoscopy
Intra-operative
covered SEMS
Post-operative
endoscopy
Post-operative
covered SEMS
Post-operative
pigtail drain
Time to
radical
surgery
Type of
radical
surgery
EWL (%)
1 56 Female 35 8 Abscess 2 0 0 8 4 0 79 GJ 22
2 33 Female 44 248 Pulmonary signs 3 0 0 11 8 0 248 GJ 98
3 23 Female 40 3 Peritonitis 5 0 0 4 1 0 153 TG 116.8
4
a
53 Female 36 1 Systemic inflammation 2 1 1 6 6 2 124 TG 31.9
GJ Roux-en-Y gastrojejunostomy at the gastric leak orifice, TG total gastrectomy, BMI body mass index, SEMS self-expandable metallic stent, EWL excess weight loss
a
Patient died
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treatments had a high success rate (84%) but required a very
long cumulative length of stay.
Gastric leak represents one of the most dangerous com-
plications of bariatric surgery [17]. In the literature, the
incidence of GL after LSG ranges from 0% to 20% (after
gastric banding removal) (Table 3). Most GL occur in the
upper third of the staple line [25]. In our experience, GL can
be characterized by its time to diagnosis, site, and clinical
aspect. Unlike Csendes et al. [30], we chose to distinguish
between only two types of time to diagnosis: early- and
delayed-onset. We believe that our classification of GL
facilitates its standardized management.
Local risk factors for GL include unsatisfactory healing
of the suture line, inadequate blood supply, infection, and
inadequate oxygenation with subsequent ischemia [32].
Anastomotic leak factors described in literature include
age, obesity (BMI >60), nutritional status, and a history of
laparoscopic gastric banding (with a thin, fragile gastric wall
due to fibrosis). Some authors [26] distinguish between
mechanical and ischemic causes of post-LSG GL. We also
think that the “learning curve”in bariatric surgery influences
the GL rate (our GL rate before October 2007 was 5.1% vs.
3% for the present study period) [31]. Prevention of GL
remains challenging. Many processes have been described
in the literature and include continuous seroserous suture
[15], the use of fibrin sealants (Tissucol® and Vivostat®)
along the staple line, and use of a nasogastric tube for at least
24 h [32]. The literature appears to support the use of
buttressing material to reduce post-operative bleeding
from the staple line, but there does not appear to be
any evidence to suggest that this technique reduces staple
line leakage [33,34].
In the literature, the clinical presentation of GL ranges
from a complete lack of symptoms to the presentation of
peritonitis, septic shock and multi-organ failure [32].
According to Tan et al. [33] and de Aretxabala et al. [35],
early-onset GL presents with severe, sudden abdominal pain
(together with fever, nausea, and vomiting), whereas
delayed-onset GL is usually of a more insidious nature (with
gradually increasing abdominal discomfort and fever).
Patients with early-onset GL show signs of sepsis caused
by gastrointestinal contents in the peritoneal cavity and they
require at least a surgical lavage and the placement of drains
[33]. For patients with delayed-onset GL, fluid frequently
collects near to the stomach remnant and does not spread to
the rest of the cavity [35]. In our experience, four clinical
presentations have approximately the same frequency: sys-
temic signs of inflammation, peritonitis, abscess, and pul-
monary symptoms. Pulmonary symptoms can be caused by
a sub-phrenic abscess (in both early- and delayed-onset GL)
or complex bronchogastric fistula (delayed-onset GL). Med-
ical and surgical teams must be aware of initial, atypical
presentations or those occurring during follow-up: (1) bron-
chogastric fistulas (revealed by chronic cough and managed
non-conservatively with a pulmonary lobectomy (according
to thoracic surgical team)), (2) acute hematemesis revealing
a left gastric artery aneurysm associated with fistula and
SEMS, and (3) a typical Wernicke–Korsakoff syndrome
linked to vitamin deficiency in patients who are, in fact,
subjected to long-term fasting.
The management of GL is challenging, resource-intensive
[33] (with medical, radiological, endoscopic, and surgical
Table 3 Incidence of gastric leak after laparoscopic sleeve gastrectomy
Authors Year Patients (n) Proportion of
gastric leaks (%)
Hann et al. [18] 2005 130 0.7
Hamoui et al. [19] 2006 118 0.8
Serra et al. [17] 2007 993 0.6
Skrekas et al. [20] 2008 93 4.3
Lalor et al. [21] 2008 148 0.7
Moy et al. [22] 2008 135 1.4
Kasalicky et al. [23] 2008 61 0
Arias et al. [24] 2009 130 0.7
Burgos et al. [25] 2009 214 3.2
Casella et al. [26] 2009 200 3
Stroh et al. [27] 2009 144 7
Frezza et al. [28] 2009 53 3.7
Ser et al. [29] 2010 118 3.39
Csendes et al. [30] 2010 343 4.66
Table 4 Endoscopic treatment
Authors Year Number of
patients
Number of
covered SEMS
Success
rate (%)
Migration
rate (%)
Casella et al. [26] 2009 5 11 100 9
Eisendrath et al. [36] 2007 12 ? 81 ?
Serra et al. [17] 2007 3 7 66 14
Eubanks et al. [37] 2008 19 34 84 58
Tan et al. [33] 2010 14 8 50 25
Our series 2011 25 50 84 8
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procedures), and necessarily multidisciplinary. In order to
optimize treatment, our institution created a dedicated care
team for bariatric complications.
Surgical treatment of GL has been validated in two
indications: at the time of diagnosis for early-onset GL and
during follow-up for GL patients presenting severe sepsis or
multi-organ failure. The aims of this surgery are threefold
[33]: (1) to wash out contaminated peritoneal fluid or col-
lections, (2) to establish adequate drainage by placing drains
around the GL site, and (3) to establish an enteric feeding
route (via a feeding jejunostomy). Burgos et al. [25] sug-
gested a therapeutic algorithm based on the classification of
GL according to upper gastrointestinal tract studies (type I
or type 2). According to Jurowich et al. [39], GL manage-
ment is based according to its location and abdominal drain-
age. We consider that all cases of early-onset GL require
initial re-operation. Operations to simply repair the fistula
have a high recurrence rate because of the surrounding
inflammatory tissue and ischemic edges [26,33].
Radiological percutaneous drainage was justified in
delayed-onset GL [26]. This radiological treatment is a
temporary measure while waiting for a clinical improvement
and endoscopic drainage. The drawback of this procedure is
the creation and potentially long-term presence of an
external fistula.
As in Lewis–Santy esogastrectomy, endoluminal stents
have been employed as a temporary procedure for “bypass-
ing”fluids from the defective area while healing occurs
[35]. Casella et al. [26] suggested that the staple line leak
can be safely and successfully managed without reoperation
in patients with hemodynamic stability (rate of success of
100%). Eisendrath et al. [36] reported a success rate of 75%
for the treatment of fistulas with stents and Eubanks et al.
[37] reported a success rate of 89%. Tan et al. [33] reported
a success rate for closure of only 50% due to stent-related
complications. Other studies have suggested routine stent
removal no later than 6 weeks in order to avoid tissue
hyperplasia and difficult extraction [17,38]. Tolerance to
stents is variable (nausea, vomiting, drooling, and retroster-
nal discomfort) [17], but this set of symptoms tends to
disappear after the first few days. Covered SEMS also
present significant morbidity–mortality, with migration be-
ing one of the main concerns (Table 4). The high migration
rate has been explained by the “abnormal”placement of the
stent along the last portion of the esophagus and the gastric
pouch [26]. The type of stent used is not related to the
migration rate [35]. In our study, we observed a left gastric
artery aneurysm (diagnosed before acute hematemesis) after
parietal gastric ulceration related to a covered SEMS.
We are not aware of any publications on the efficacy and
safety of pigtail drains in post-LSG GL (as in the manage-
ment of pseudocyst in chronic pancreatitis). In our study,
pigtail drains were more effective and safer than covered
SEMS. The pigtail drains were better tolerated, required
fewer procedures per patient, and had a shorter healing time
than the covered SEMS. During this treatment, patients were
allowed to drink water ad libitum. The morbidity–mortality
of pigtail drains was lower. The main indication for the use
of pigtail drains was late-onset GL after LSG (when the GL
was present as a well-delimited collection or abscess).
“Treatment success”for post-LSG GL was defined as the
absence of contrast agent leakage on CT scan and endoscopy
after the removal of a permanently covered SEMS or pigtail
drain. However, “treatment failure”was very difficult to
define since the timing and the number of endoscopic pro-
cedures was not mentioned in the literature. In our experi-
ence, definition of treatment failure must include the number
of endoscopic procedures, poor clinical or biochemical tol-
erance, and an atypical presentation (such as pulmonary
complications, which contra-indicate conservative manage-
ment). Once curative surgery has been decided, total gastrec-
tomy or Roux-en-Y gastrojejunostomy can be considered.
The latter procedure appears to be the less aggressive of the
two and limits injury to the gastric cavity. Long-term data are
necessary to determine the best approach when conservative
treatment is unsuccessful.
Post-LSG GL is a problematic complication and is asso-
ciated with specific morbidity and mortality. Multidisciplin-
ary care is necessary and can involve surgical, endoscopic,
radiologic, and pharmacologic treatments. Although these
complications can usually be resolved, they often necessi-
tate many surgical or endoscopic interventions and long stay
in the hospital.
Conflicts of Interest All contributing authors declare that they have
no conflicts of interest.
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