title: Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity.
abstract: BACKGROUND
  Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of this study was to describe the clinical presentation and outcomes of treatment in patients who develop anastomotic leaks after Roux-en-Y gastric bypass for obesity.
  
  
  METHODS
  Prospectively collected data on 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers were reviewed.
  
  
  RESULTS
  Sixty-three patients (2.1%) developed anastomotic leaks (open, 2.1%; laparoscopic, 2.1%) at a median of 3 days (range 0 to 28 days) after Roux-en-Y gastric bypass. Symptoms and signs included tachycardia (72%), fever (63%), or abdominal pain (54%). Upper gastrointestinal series and CT demonstrated leaks in only 17 of 56 (30%) and 28 of 50 (56%) patients, respectively; when done jointly, both studies were negative in 30% of patients. The 68 anastomotic leaks occurred at the gastrojejunostomy (49%), excluded stomach (25%), jejunojejunostomy (13%), gastric pouch (9%), and uncertain location (4%). Forty patients (63%) required 58 reoperations for drainage of intraabdominal collections (55%), repair of anastomotic defects (34%), or revision of the leaking anastomosis (11%), with an overall morbidity of 53% and mortality of 10%. Nonoperative treatment was successful in 23 of 26 patients, with an overall morbidity of 61% and no mortality (p=NS versus operative). Operative treatment was more common in patients with hypotension or oliguria (p < 0.01).
  
  
  CONCLUSIONS
  Lack of specificity in clinical presentation and imaging studies make diagnosing anastomotic leaks challenging, so operative exploration should be part of the diagnostic algorithm. Nonoperative treatment is safe and effective in a subset of patients who exhibit stable hemodynamic parameters and are known to have controlled leaks.
authors.affiliation: Interdisciplinary Obesity Treatment Group, Department of Surgery, University of South Florida Health Sciences Center, Tampa, FL 33601, USA.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Gonzalez
authors.forename: Michael G
authors.initials: MG
authors.lastname: Sarr
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Smith
authors.forename: Mercedeh
authors.initials: M
authors.lastname: Baghai
authors.forename: Michael
authors.initials: M
authors.lastname: Kendrick
authors.forename: Samuel
authors.initials: S
authors.lastname: Szomstein
authors.forename: Raul
authors.initials: R
authors.lastname: Rosenthal
authors.forename: Michel M
authors.initials: MM
authors.lastname: Murr
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis* / Q000601:surgery*; D011379:Prognosis; D011446:Prospective Studies; D012086:Reoperation; D014057:Tomography, X-Ray Computed