Original article
Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation

https://doi.org/10.1016/j.soard.2015.04.012Get rights and content

Abstract

Background

Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL.

Objectives

Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation.

Setting

University hospital, France, public practice.

Methods

All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment.

Results

Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day≤7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14–423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P≤ .05).

Conclusions

Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.

Section snippets

Population

A retrospective analysis of prospectively gathered data on a group of patients with GL after the performance of primary SG (with no history of bariatric surgery) or revisional SG (with a history of gastric banding, gastric banding removal, and SG in the same procedure), between November 2004 and March 2014, was performed.

Inclusion criteria

Patients included in the study had to meet the following criterion: post-SG GL visualized during an abdominal computed tomography (CT) scan, endoscopy, or surgery.

Exclusion criteria

Patients who

Status before the primary LSG

During the study period, 1205 patients underwent primary SG in the authors’ institution and 239 patients underwent secondary SG (94 SGs with a history of gastric banding removal, 115 gastric banding removals and SG in the same procedure, and 30 repeat SGs). Over the same period, 86 patients were managed for post-SG GL in the authors’ institution. Forty-three patients had undergone SG (the incidence of GL after all types of SG performed was 2.9%), whereas the other 43 had been referred after SG

Discussion

The SG is an increasingly popular bariatric procedure because of its relative ease (compared with RYGB), a short learning curve (between 28 and 50 operations) [23], [24], a low complication rate (with a GL rate around 2% [1], [25]), good long-term weight loss (i.e., an excess weight loss≥50% more than 5 yr after SG [24], [26], [27]), and its ability to effectively correct obesity-related co-morbidities [28].

Nevertheless, postoperative GL is a difficult, life-threatening complication to manage;

Conclusions

Gastric leak is a feared complication after SG. Most cases of GL can be adequately treated by incorporating endoscopic stenting and DPS appears to be a superior treatment option to CS. According to the present analysis of all the patients with GL treated in the authors’ institution, surgery for persistent GL should be performed within 120 days of discovery of the leak. Large, retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

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