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This Month’s Featured Expert: Alex Gandsas, MD, MBA, FACSDr. Gandsas is Professor and Chair, Department of Surgery, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine (UMDNJ-SOM), Stratford, New Jersey.
A 35-year-old woman presented to the treating physcian’s facility with fever, left shoulder pain, and leucocytosis. At the time of her visit, she was 10 days postoperative a sleeve gastrectomy (SG) for morbid obesity. A computed tomography (CT) scan of the abdomen showed a large left upper quadrant air-fluid collection. After percutaneous drainage, culture, and antibiotics, the patient was put on total parenteral nutrition (TPN) and instructed nil per os (NPO) or “nothing by mouth.”
What are the next steps? How long until a stent can be placed and work successfully? Can a patient be started on oral feed after stenting? For how long can stents be kept in place? If after removal of the stent, the leak still persists, what are the next treatment options? How long should the treating physician wait for reoperative surgery?
Due to its relative simplicity and effectiveness, laparoscopic SG has become an increasingly popular surgical option in the treatment of morbid obesity.[1,2] However, the procedure does create a long gastric staple line that is vulnerable to certain complications. Gastric leak, with an incidence of 0 to 5.3 percent[3,4] and a 0.4-percent mortality rate,5 is one of the most serious and potentially life-threatening complications following laparoscopic SG. While certain core principles are agreed upon and guide management, the role of surgery is changing. Current trends favor nonsurgical therapies for adequately drained, proximal leaks (near the angle of His) in stable patients. In this select patient population, endoluminal stenting has emerged as a promising adjunct to the nonoperative armamentarium for poor-healing leaks;[6,7] however, definitive studies are needed to further define their role and guidelines for use.
Gastric leaks can cause significant morbidity, including cutaneous fistulas, peritonitis, abscess formation, sepsis, organ failure, and death. Early diagnosis is critical and requires a high index of suspicion. The most reliable clinical indicator may be tachycardia, but the clinical presentation may also include leukocytosis, fever, tachypnea, and abdominal pain, each of which should prompt further investigation with a CT scan as was performed in this case. The timing of presentation (more than 8 days after surgery) and the presence of an air-fluid collection in the left upper quadrant are classically consistent with a late gastric leak.[8] In a stable patient with a localized collection such as this and no signs of generalized sepsis, a conservative, nonsurgical approach is preferred. Percutaneous drainage under CT guidance is appropriate to manage the leak and septic state. Concurrently, the patient should be made NPO and nutritional support should be initiated along with intravenous (IV) fluids and broad-spectrum antibiotics, including antifungals. Drainage, nutrition, and antibiotics are the undisputed cornerstones of gastric leak management.
At this point in the clinical course, some institutions recommend immediate stent placement; however, data documenting reduced hospital stay and costs are lacking. A well-drained leak with nutritional support and sepsis control are the mainstays of treatment and, in many patients, will result in leak closure without further treatment. In my experience, in a stable patient, it is reasonable to wait 48 to 72 hours after percutaneous drainage before re-assessing the leak with another contrast study. If the fistula has been sealed off and no extravasation of contrast is observed, then I continue TPN and reassess the leak in two weeks. If the follow-up contrast study fails to demonstrate extravasation and the drain output has significantly decreased, then I attempt oral feeding and re-evaluate. However, if the interval study confirms a persistent gastric fistula, I continue with a minimally invasive approach and conduct an upper endoscopy to localize the defect and potentially place a stent.
Gastric sleeve leaks usually occur proximally along the staple line close to the gastroesophageal junction where currently used endoluminal stents provide the best sealing effect. During upper endoscopy, resolution clips can be applied close to the defect followed by the placement of an endoscopic removable covered stent as suggested by several authors.[4,6] Stenting creates a containment barrier for gastric contents along the staple line and reduces high intraluminal pressure, theoretically allowing the defect to heal and close. After stent placement, patients can begin oral intake and may be discharged, improving the patient’s quality of life and avoiding the risks associated with long-term TPN. In addition, the stent guards against potential stricture formation. Silicon-covered esophageal stents have been most commonly used. I recommend using larger diameter stents (32mm) to prevent stent migration, a well-described complication affecting up to one-third of patients.[6,9,10] Some authors also recommend using longer 14cm stents to minimize migration.[6]
Although specific data are lacking, authors generally recommend keeping the stent in place for at least six weeks while monitoring drain output. Following this interval, I perform a contrast study 2 to 3 weeks after stent placement to assess the fistulous tract. If the fistula is not identifiable on x-ray, then I remove the stent while maintaining the percutaneous drain for an additional week to ensure that the fistula has not recurred following stent removal. The drain is finally removed following a negative contrast study.
Definitive outcome data following stent placement are lacking. The time required for leak closure is highly variable with reports ranging from 21 days to 4 months.[10] Therefore, as long as the patient remains stable without signs of sepsis, patience must be emphasized in order to maximize conservative management and avoid the morbidity associated with reoperation. Small series studies report success rates ranging from 50 to 100 percent.[6,11] However, in the series reporting 50-percent success, some of the stents were removed due to complications from the stent placement.[11]
Reoperation should be reserved for rare cases where a leak persists despite stent placement and a substantial period of time has passed or for patients who develop generalized sepsis during conservative management or in the case of a distal leak. Several techniques have been described to address the nonhealing fistula following SG. Court et al12 successfully controlled a fistula by placing a t-tube through the staple line defect. Invagination of the leak site has been proposed by Jurowich et al[13] in an attempt to provide a “natural” barrier to the extravasation of gastric juices. Oversewing the staple line defect with omental flap coverage has also been attempted.[14] However, the technique is usually futile due to the fragility of local tissues.[10] Resuturing or staple line resection have been suggested for the treatment of distal leaks.[13]
Other operative options include the injection of fibrin glue into the defect, construction of a Roux-en-Y loop if the defect is large, and finally total gastrectomy. In patients with long-standing leaks, closure of the defect may not be possible due to inflammatory changes; therefore, lavage and wide drainage may be the best option.
Although reoperation has its place in the treatment armamentarium for gastric leak following SG, current trends favor reoperation as the exception after conservative therapies have been exhausted.
The management of a gastric leak following SG should be based on a prompt control of the septic state and providing adequate nutrition. Control of the fistula can be achieved by the use of covered stent with or without the combination of additional surgery.
Successful treatment was achieved and the fistula closed seven weeks after percutaneous drainage of the collection and placing the patient NPO.
12. Court I, Wilson A, Benotti P, et al. T-tube gastrostomy as a novel approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case report and review of the literature. Obes Surg. 2010;20(4):519–522.