Leaks worst and maybe the most fearful..

Leaks in GASTRIC BYPASS AND SLEEVE GASTRECTOMY are among the worst and maybe the most fearful complications in bariatric surgery.

 

After the initial diagnosis and sepsis stabilization an endoscopic therapeutic plan should be assigned.

 

From the healing perspective, it seems like the two procedures has different outcomes in term of leakage.

 

On the gastric bypass most of the leaks heals up to 30 days and a conservative approach is advisable.

 

After this period and endoscopy should be performed having in mind the observation of he pouch itself with close attention to the staple line at were the greater curvature was stapled and transected, the gastro-jejunostomy (GJ) and the alimentary limb.

 

The master statement that a to treat a digestive leak the obstructions (stenosis) have to be removed always applies and if the endoscope do

 

not pass trough the GJ, dilation should be done as first move. Traditional

therapeutic endoscopy like biological glue, clips and meshes should be used to

complement the dilation, in combination or as single therapy. Some situations

like staple line disruption, gastro-pleural and His angle leaks predicts that the

leak will not respond well to this approach and demands a more advanced

approach like the use of stents with healing rates over 90% (23 patients) with

around 40d of implant as our group hap presented on Argentina IFSO meting in

2008.

 

If the gastric bypass has a well-established endoscopic approach, the sleeve gastrectomy leaks points in another direction in terms of healing outcomes specially when it comes from angle of His (EG junction) and is performed using thinner boogies like 32 to 36fr.

 

On opposite of the gastric bypass that tends to heal with conservative approach, the his angle fistula (the most frequent one) of sleeve gastrectomy tends to become chronic and demands an alternative endoscopic approach that can be divided in early (up to 30d) and late.

 

Besides the medical literature is poor in addressing papers over this matters the clinical practice on reference centers that receive those complications acknowledge that the traditional endoscopic approach of “closing the hole” do not achieves a high leak healing rate.

 

The His angle leak has a specific group of conditions that collaborates to its unusual pattern as follows;

 

the His angle itself with poor irrigation,

 

the absence of the remnant stomach to “block” the leak,

 

the “physiologic” obstruction of the pylorus,

 

the real narrowing at the level of incisura angularis,

 

the body-antrum axis deviation and the helix sleeve” possibilities, the longest staple line on bariatric surgery, the fact that being so “high” that it is under negative pressure of the thorax and the fact that the sleeve gastrectomy is high pressure “closed” system instead of a “drainage” procedure like the bypass.

 

That said, on the sleeve gastrectomy leaks our first line approach for early leaks are the stents and if we receive the patients after 30d the patients are treated by endoscopy with pneumatic dilation and associated septomy.

 

Both approaches release the pressure on the lumen by dilating the pylorus (pneumatic dilation), the incisura and the gastric body, also correcting the body-antrum axis.

 

If the endoscopic treatment fails in-between 6 months, surgical approach should be considered. At our service this strategy was successfully used to treat 32 patients except one that was referred to surgical treatment after 8 months.

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