title: Routine intraoperative leak testing for sleeve gastrectomy: is the leak test full of hot air?
abstract: BACKGROUND
  Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0% to 8%. Many surgeons routinely test the staple line with an intraoperative leak test (IOLT), but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak.
  
  
  METHODS
  Retrospective review of all SGs performed over a 7-year period was conducted. Cases were grouped by whether an IOLT was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed.
  
  
  RESULTS
  Five hundred forty-two SGs were performed between 2007 and 2014. Thirteen patients (2.4%) developed a postop staple line leak. The majority of patients (n = 494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increase leak rates when a routine IOLT was performed vs no routine IOLT (2.6% vs 0%, P = .6).
  
  
  CONCLUSIONS
  The performance of routine IOLT after SG provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.
authors.affiliation: Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA. Electronic address: jason.r.bingham4.mil@mail.mil.
authors.forename: Jason
authors.initials: J
authors.lastname: Bingham
authors.affiliation: Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Lallemand
authors.affiliation: Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
authors.forename: Morgan
authors.initials: M
authors.lastname: Barron
authors.affiliation: Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
authors.forename: John
authors.initials: J
authors.lastname: Kuckelman
authors.affiliation: Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
authors.forename: Preston
authors.initials: P
authors.lastname: Carter
authors.affiliation: Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Blair
authors.affiliation: Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Martin
mesh_terms: D000293:Adolescent; D000328:Adult; D057868:Anastomotic Leak / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery; D015992:Body Mass Index; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000175:diagnosis / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D017792:Surgical Stapling; D016896:Treatment Outcome; D055815:Young Adult
keywords: Bariatric surgery; Intraoperative leak test; Postoperative staple line leak; Sleeve gastrectomy; Sleeve gastrectomy complications; Staple line dehiscence