Bariatric Times

Sleeve Gastrectomy 2015

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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A10 Bariatric Times • April 2015 • Supplement A 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY S taple line leak is a dreaded complication after laparoscopic sleeve gastrectomy (LSG). In an updated position statement on sleeve gastrectomy as a bariatric procedure with analysis of 36 studies and 2,570 patients, the incidence of staple line leaks was reported to be 2.2 percent. 1 The majority of staple line leaks associated with sleeve gastrectomy occur high on the sleeve, immediately below the level of the gastroesophageal junction. Causes for staple line leaks are multifactorial and include narrowing of the gastric incisura resulting in a partial obstruction leading to a high-pressure system, stapler malformation or failure due to the thickness of the tissue, and poor tissue perfusion leading to staple line disruption. The most common condition observed with staple line leaks after LSG is the presence of a concomitant distal obstruction at the level of the gastric incisura. The presence of a distal obstruction or narrowing results in distention of the proximal gastric sleeve, leading to a high-pressure system and thereby contributing to the development of a staple line leaks. Treatment for sleeve leaks include laparoscopic drainage and endoscopic placement of a covered esophageal stent. The use of an esophageal stent for management of sleeve leaks is an off-label use. The United States Food and Drug Administration (FDA) indication for esophageal stenting is for management of malignant obstruction or obstruction in a setting of fistula. The goals in management of sleeve leaks using esophageal stenting include endoluminal covering of the staple line defect and dilation of the distal obstruction at the level of the gastric incisura. The stent therapy, therefore, opens the distal obstruction and provides a pathway for diversion of enteral fluid leading to tissue healing. The esophageal stent is normally left in place for 3 to 4 weeks and can be removed endoscopically thereafter. Another cause for staple line leaks is stapler malformation or failure. This is particularly prevalent in revisional cases whereby the gastric tissue can be thick and inflamed. For example, conversion of laparoscopic adjustable gastric banding (LAGB) to LSG can lead to a higher staple line leak rate than primary sleeve gastrectomy cases. Staple line leaks normally occur along the gastric staple line in the region of the previous gastric banding. To minimize the risk for leaks in these revisional cases, some surgeons routinely perform the conversion in two stages. The first stage would be removal of the gastric band. This is followed by performance of the sleeve gastrectomy in 3 to 6 months. Another important factor that has been implicated in staple line leaks is poor tissue perfusion leading to poor tissue healing and staple line disruption. Recent technological advances in fluorescence imaging now allow surgeons the ability to evaluate tissue perfusion in real-time. After completion of the sleeve gastrectomy (Figure 1), indocyanine green (ICG) can be injected intravenously, and within 30 seconds, tissue perfusion can be observed using a fluorescence imaging system (Pinpoint ® , • It is important for surgeons to avoid narrowing of the gastric incisura during construction of the gastric sleeve • Err on the side of using a thicker stapler load in revisional cases to avoid stapler malformation or stapler failure. • In complex revisional cases with potential for development of tissue ischemia, the use of fluorescence imaging will allow surgeons to identify the site of poor tissue perfusion in real-time, and operative interventions can be performed to minimize the risk of postoperative staple-line leaks. KEY POINTS Tissue Perfusion in Sleeve Gastrectomy NINH T. NGUYEN, MD Vice-Chair, Department of Surgery, University of California Irvine School of Medicine, Irvine, California, United States B ariatric Times. 2015;12(4 Suppl A):A10–A11. DISCLOSURE: Dr. Nguyen is a speaker for and/or has received honorarium from Novadaq Inc., Bonita Springs, Florida, United States. ADDRESS CORRESPONDENCE TO: Dr. Ninh T. Nguyen, 333 City Blvd. West, Suite 1600, Orange, CA 92868; Phone: (714) 456-8598; E-mail:

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