title: Definitive surgical management of staple line leak after sleeve gastrectomy.
abstract: BACKGROUND
  Sleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature.
  
  
  OBJECTIVE
  This study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results.
  
  
  METHODS
  Single surgeon experience based at a tertiary university hospital in Beirut, Lebanon.
  
  
  METHODS
  Retrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013.
  
  
  RESULTS
  Ten patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m(2), respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13-39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1-7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m(2) versus 30 kg/m(2)) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5-55.9 mo) with an average percentage excess weight loss of 74% (57%-120%).
  
  
  CONCLUSIONS
  Definitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.
authors.affiliation: American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon. Electronic address: bs21@aub.edu.lb.
authors.forename: Bassem Y
authors.initials: BY
authors.lastname: Safadi
authors.affiliation: American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon.
authors.forename: Ghassan
authors.initials: G
authors.lastname: Shamseddine
authors.affiliation: American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon.
authors.forename: Elias
authors.initials: E
authors.lastname: Elias
authors.affiliation: American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon.
authors.forename: Ramzi S
authors.initials: RS
authors.lastname: Alami
mesh_terms: D000328:Adult; D057868:Anastomotic Leak / Q000209:etiology / Q000601:surgery*; D050110:Bariatric Surgery / Q000009:adverse effects / Q000379:methods; D015992:Body Mass Index; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D006785:Hospitals, University; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000379:methods; D007861:Lebanon; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000175:diagnosis / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis / Q000601:surgery; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D017792:Surgical Stapling / Q000009:adverse effects* / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Bariatric surgery; Complication; Fistula; Leak; Sleeve gastrectomy