Malignant Leakage After Sleeve Gastrectomy: Endoscopic and Surgical Approach

• Published in: Obesity surgery Vol. 30; no. 11; pp. 4459 - 4466
• Main Authors: Caiazzo, Robert, Marciniak, Camille, Wallach, Ninon, Devienne, Magalie, Baud, Gregory, Cazauran, Jean-Baptiste, Kipnis, Eric, Branche, Julien, Robert, Maud, Pattou, François
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.11.2020; Springer Nature B.V; Springer Verlag
• Subjects: Anastomotic Leak - etiology; Anastomotic Leak - surgery; Endoscopy; Gastrectomy - adverse effects; Gastric Bypass; Gastric Fistula - etiology; Gastric Fistula - surgery; Gastrointestinal surgery; Humans; Laparoscopy; Life Sciences; Medicine; Medicine & Public Health; Obesity, Morbid - surgery; Original Contributions; Postoperative Complications - etiology; Postoperative Complications - surgery; Reoperation; Retrospective Studies; Surgery; Leakage; Chronic; Management; Sleeve gastrectomy
• ISSN: 0960-8923; 1708-0428
• DOI: 10.1007/s11695-020-04818-4

Purpose Gastric leak occurs after sleeve gastrectomy (SG) in 2% of cases. Most staple-line disruptions (SLD) can be successfully treated with first-line endoscopic procedures. Less favorable situations may lead to more complex therapeutic strategies, like conversion to Roux-en-Y gastric bypass (RYGBP). The aim of our study is to predict the factors of endoscopic treatment failure and to assess the safety of conversion to RYGBP. Methods We included all patients treated in two centers of academic excellence ( n  = 100) between 2013 and 2017 who had a malignant SLD after SG. A “malignant” leakage met one of the following poor prognosis criteria suggested in the literature: unsuccessfully treated by the first-line endoscopic treatment; generalized peritonitis; anatomical anomalies; gastro-cutaneous or gastro-pleural fistula (GCF/GPF); or chronic leaks (> 4 weeks). Results No deaths occurred during the follow-up (20 ± 12 months). The endoscopy reported an anatomically abnormal gastric tube in 35 (35%) patients (stenosis [ n  = 21 (21%)], twist [ n  = 9 (9%)], or both [ n  = 5 (5%)]). We could maintain the SG in place in 92% of cases without stenosis, twist, or GCF/GPF. Conversion to RYGBP due to leakage was necessary in 37 (37%) patients. Stenosis, twist, or GCF/GPF significantly prevented healing in multivariate analysis (respectively: p  = 0.020, OR = 0.17, and p  < 0.001, OR = 0.07—logistic regression). Conclusion Endoscopy is the treatment of choice for the management of chronic leaks after SG. The association of anatomical anomalies and GCF/GPF should lead to consideration of conversion to RYGBP.