title: Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift.
abstract: BACKGROUND
  During the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals.
  
  
  METHODS
  We reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded.
  
  
  RESULTS
  There were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient.
  
  
  CONCLUSIONS
  EIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.
authors.affiliation: Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08844, USA. rbrolin@njbariatricspc.com
authors.forename: Robert E
authors.initials: RE
authors.lastname: Brolin
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Lin
mesh_terms: D000368:Aged; D057868:Anastomotic Leak / Q000188:drug therapy / Q000601:surgery*; D005260:Female; D015718:Fibrin Tissue Adhesive / Q000627:therapeutic use; D015390:Gastric Bypass / Q000009:adverse effects*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D007902:Length of Stay; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D012086:Reoperation; D014014:Tissue Adhesives / Q000627:therapeutic use
chemical_list: D015718:Fibrin Tissue Adhesive; D014014:Tissue Adhesives