title: Management of staple line leaks after sleeve gastrectomy in a consecutive series of 378 patients.
abstract: BACKGROUND
  Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance as a stand-alone bariatric procedure with proven efficacy on weight loss and obesity-related comorbidities. A specific and potentially severe complication of LSG is the staple line leak (SLL). Our aim was to report the SLL rate and its management in a prospective cohort of 378 LSGs.
  
  
  METHODS
  A total of 378 patients underwent LSG from July 2005 to July 2011. The gastric transection was performed by an initial 60 mm firing of 4.5 mm staples at the antrum and successive 60 mm firings of 3.5 mm staples at the gastric body and fundus toward the left diaphragmatic crus. A 36 Fr bougie was used to calibrate the gastric tube. The staple line was systematically reinforced with a partial-thickness running suture.
  
  
  RESULTS
  The overall complications and SLL rate were 20/378 (5.29%) and 9/378 (2.38%), respectively. SLLs were managed by laparoscopic (n=2) or open (n=1) exploration, drainage and endoscopic self-expandable covered stent, computed tomography-guided percutaneous drainage (n=2), or a self-expandable covered stent alone (n=4). Medical support including total parenteral nutrition and adapted antibiotics was started in all patients. The combined treatment modalities were successful in all cases.
  
  
  CONCLUSIONS
  SLL was the most common complication of LSG accounting for half of the overall complications. Percutaneous drainage and self-covered stents combined with antibiotics and parenteral nutrition are effective for SLL and should be proposed as first-line treatment in stable patients.
authors.affiliation: Department of General, Digestive and Endocrine Surgery, IRCAD-IHU, University of Strasbourg, Strasbourg, France Department of General Surgery, UCSC, Catholic University of Sacred Heart, Policlinico Gemelli, Rome, Italy IRCAD-AITS, Show Chow Health Care System, Changhua, Taiwan.
authors.forename: Michel
authors.initials: M
authors.lastname: Vix
authors.forename: Michele
authors.initials: M
authors.lastname: Diana
authors.forename: Ludovic
authors.initials: L
authors.lastname: Marx
authors.forename: Cosimo
authors.initials: C
authors.lastname: Callari
authors.forename: Hurng-Sheng
authors.initials: HS
authors.lastname: Wu
authors.forename: Silvana
authors.initials: S
authors.lastname: Perretta
authors.forename: Didier
authors.initials: D
authors.lastname: Mutter
authors.forename: Jacques
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D000328:Adult; D057868:Anastomotic Leak / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D004322:Drainage; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D010288:Parenteral Nutrition; D011446:Prospective Studies; D015607:Stents; D017792:Surgical Stapling / Q000009:adverse effects*
chemical_list: D000900:Anti-Bacterial Agents
references.citation: Regan JP, Inabnet WB, Gagner M, et al.. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003;13:861–864.
references.citation: Kehagias I, Karamanakos SN, Argentou M, et al.. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI <50 kg/m2.Obes Surg. 2011;21:1650–1656.
references.citation: Karamanakos SN, Vagenas K, Kalfarentzos F, et al.. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg. 2008;247:401–407.
references.citation: Vix M, Diana M, Liu KH, et al.. Evolution of glycolipid profile after sleeve gastrectomy vs. Roux-en-Y gastric bypass: results of a prospective randomized clinical trial. Obes Surg. 2013;23:613–621.
references.citation: Zacharoulis D, Sioka E, Papamargaritis D, et al.. Influence of the learning curve on safety and efficiency of laparoscopic sleeve gastrectomy. Obes Surg. 2012;22:411–415.
references.citation: Breaux JA, Kennedy CI, Richardson WS. Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2007;21:985–988.
references.citation: Deitel M, Gagner M, Erickson AL, et al.. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7:749–759.
references.citation: Albanopoulos K, Alevizos L, Flessas J, et al.. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing two different techniques. Preliminary results. Obes Surg. 2012;22:42–46.
references.citation: Rosenthal RJ. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8–19.
references.citation: Yehoshua RT, Eidelman LA, Stein M, et al.. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg. 2008;18:1083–1088.
references.citation: Chen B, Kiriakopoulos A, Tsakayannis D, et al.. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg. 2009;19:166–172.
references.citation: Casella G, Soricelli E, Rizzello M, et al.. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg. 2009;19:821–826.
references.citation: Dapri G, Cadiere GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010;20:462–467.
references.citation: Gill RS, Switzer N, Driedger M, et al.. Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients. Obes Surg. 2012;22:560–564.
references.citation: Oshiro T, Kasama K, Umezawa A, et al.. Successful management of refractory staple line leakage at the esophagogastric junction after a sleeve gastrectomy using the HANAROSTENT. Obes Surg. 2010;20:530–534.