Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors.
BACKGROUND
Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures.


METHODS
Risk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence.


RESULTS
Pathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage.


CONCLUSIONS
This review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40 Fr, EL:1, (2) begin the gastric transection 5-6 cm from the pylorus, EL:2-3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1 cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.
Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy. angelo.iossa@gmail.com.
Angelo
A
Iossa
Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.|Gastroenterology Surgical Center (GEC), Faculty of Medicine, Mansoura University, Mansoura, Egypt.
Mohamed
M
Abdelgawad
Division of General Surgery and Weight loss Center, West Chester Hospital, University of Cincinnati, Cincinnati, OH, USA.
Brad Michael
BM
Watkins
Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.
Gianfranco
G
Silecchia
D057868:Anastomotic Leak / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control; D005743:Gastrectomy / Q000009:adverse effects*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D012307:Risk Factors
Fistula; Ideal sleeve gastrectomy; Leak; Pathogenesis; Technical tips