title: Gastric sleeve leak: a single institution's experience with early combined laparoendoscopic management.
abstract: BACKGROUND
  Sleeve gastrectomy is an effective weight loss procedure that is technically less complex than Roux-en-Y gastric bypass. However, staple line leak (SLL) remains a significant complication of this procedure with reported incidence ranging from 1%-7%. Multiple treatment strategies for SLL are reported including surgical re-exploration, percutaneous drainage, and endoscopic stenting. Our objective was to review the results of our experience with combined laparoendoscopic procedures in managing SLL.
  
  
  METHODS
  A retrospective review of patients with SLL after laparoscopic sleeve gastrectomy (LSG) between June 2008 and October 2013 was performed. Patient characteristics, operative details, and postoperative management strategies were reviewed. All patients were managed with a combination of early laparoscopic washout and endoscopic stenting.
  
  
  RESULTS
  One hundred sixty-five patients underwent LSG with SLL identified in 4 patients (2.4%). One patient was transferred from an outside institution for SLL. Average time to SLL diagnosis was postoperative day 3 (range 1-7). After diagnosis patients underwent laparoscopic washout and initial endoscopic stenting. Three patients required additional endoscopic procedures to manage stent migration, and 2 required additional procedures for peri-stent leak. Complications were managed endoscopically with stent adjustment or replacement. Patients had indwelling stents for an average of 29 days (range 15-56). Mean hospital length of stay was 30 days (range 20-42).
  
  
  CONCLUSIONS
  SLL after LSG can confer a high morbidity and mortality. Endoscopic management of SLL with stenting has been advocated because it successfully manages the leaks and avoids additional invasive procedures. Based on our experience, successful management of SLL can be achieved with an early combined laparoendoscopic approach.
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania. Electronic address: rjuza@hmc.psu.edu.
authors.forename: Ryan M
authors.initials: RM
authors.lastname: Juza
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.
authors.forename: Randy S
authors.initials: RS
authors.lastname: Haluck
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Pauli
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.
authors.forename: Ann M
authors.initials: AM
authors.lastname: Rogers
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.
authors.forename: Eugene J
authors.initials: EJ
authors.lastname: Won
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.
authors.forename: Jerome R
authors.initials: JR
authors.lastname: LynSue
mesh_terms: D000328:Adult; D003131:Combined Modality Therapy; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D015390:Gastric Bypass / Q000009:adverse effects; D005773:Gastroscopy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies; D015607:Stents; D013529:Surgical Wound Dehiscence / Q000601:surgery*; D016896:Treatment Outcome
keywords: Endoscopic stent; Leak; Sleeve gastrectomy