Almino Ramos, MD, from Brazil, discussed the management of leak after laparoscopic sleeve gastrectomy (LSG) at the 2014 Surgery of the Foregut Symposium, Coral Gables, Florida.

Laparoscopic sleeve gastrectomy has increased exponentially over the past decade. Chronic leak after LSG remains a challenging complication to manage for most bariatric surgeons. Dr. Ramos discussed the management of chronic leak and shared some of his experiences with performing gastrectomy for resistant cases.

Sleeve gastrectomy creates a perfect storm for development of a fistula at the angle of His. Physiologic obstruction due to the pylorus and mechanical obstruction from the “L” shape of the sleeve causes increased pressure inside the sleeve. The negative pressure inside the thorax compounds this process. Complete resection of the angle of His is desirable to achieve maximum weight loss. However, this might cause a leak due to the loss of blood supply in the surrounding area, leading to ischemic changes.

Initial management of leak at the angle of His remains nasoenteral feeding and drainage. Stent placement by endoscopy is one of the conventional methods used for fistula treatment. However, the anatomic position of the angle of His poses a challenge. Endoscopy has also been used for fibrin glue, mesh placement or clips. Some surgeons have proposed conversion of the sleeve into a Roux-en-Y gastric bypass.

Dr. Ramos discussed his experience with performing laparoscopic total gastrectomy for resistant cases of leak in 12 patients who already had at least one attempt with conventional treatment. Dr. Ramos concluded that, in his experience, laparoscopic total gastrectomy could be the only alternative in some cases of resistant leak and can be performed safely. These patients should wait at least three months and should initially undergo conventional methods of leak management. Surgeons should consider this procedure only after they have acquired substantial experience in bariatric and minimally invasive surgery procedures.

—Mayank Roy, MD