Introduction

Laparoscopic sleeve gastrectomy (SG) has been increasingly performed as a primary and sole weight-loss operation for morbidly obese patients. Several publications have shown a percentage of excess weight loss (%EWL) approaching that of the laparoscopic Roux-en-Y gastric bypass at both the short- and mid-term follow-up [1–7]. The fact that SG has been considered a simple and easy surgical procedure has led to its adoption by a large number of surgeons. Compared to gastric bypass and biliopancreatic diversion, SG seems to have a smaller risk of complications, but the potential complications can be as severe as those associated with other techniques. Due to the long staple line and the altered intragastric pressure, SG is specifically associated with two significant complications: hemorrhage and leakage. The most dreaded complication after SG is a gastric leak, which most commonly occurs at the upper staple line near the gastroesophageal junction. This complication, if not identified and treated quickly and aggressively, may lead to severe abdominal sepsis, which might progress to either a chronic gastric fistula or to multiorgan failure and patient demise [8–12]. The purpose of the present study was to determine the postoperative course, clinical presentation and treatment of complications after SG in a consecutive group of obese patients.

Materials and methods

A retrospective review of our prospectively collected database was used to evaluate all patients who underwent sleeve gastrectomy between January 2006 and October 2012. During the study period, 153 patients underwent SG. The baseline data are presented in Table 1. All patients were required to have psychological screening, routine labs, electrocardiogram, gastroscopy, esophageal manometry, 24-h pH monitoring, pulmonary function studies and a medical evaluation. All patients entering our practice requesting bariatric surgery were offered four procedure options: adjustable gastric banding, laparoscopic gastric bypass, laparoscopic sleeve gastrectomy and SIL sleeve gastrectomy.

Table 1 Patient demographics
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The exclusion criteria were heavy sweet-eaters, patients with hiatal hernia or with functional disorders of the lower esophageal sphincter and patients with psychiatric disorders or addiction to either drugs or alcohol.

All patients were considered as candidates provided they did not have the above-mentioned exclusion criteria. All patients were preoperatively evaluated by a dietician and also by related specialties based on their individual needs. The final decision for surgery was made by both the surgeon and the patient after a detailed discussion. All the patients were well informed of the possible options, along with the risks and the benefits of all the bariatric procedures suitable for them. All patients were scheduled for sleeve gastrectomy as a primary definitive procedure. Informed consent was provided by all patients.

Prior to surgery, the patients received antibiotics for infectious prophylaxis. During the entire hospitalization period, prophylaxis for deep vein thrombosis comprised daily injections of low molecular weight heparin (starting 12 h prior to surgery) and the use of compression stockings.

The postoperative outcomes in terms of the percent excess weight loss (%EWL) and complication rates were evaluated at a follow-up of 18.4 months.

Surgical technique for laparoscopic sleeve gastrectomy

During the procedure, the patient was placed in the supine position. The surgeon stood between the legs of the patient and the assistant stood on the left side. The SG was performed laparoscopically using a four-trocar technique. Pneumoperitoneum was established at a pressure of 14 mmHg. We used a 30° video laparoscope. Using a 5-mm LigaSure device (Covidien) and a 5-mm flexible grasper, the greater curvature of the stomach was mobilized, starting from a point 6 cm proximal to the pylorus, staying close to the wall of the stomach all the way up the greater curvature to the angle of His, dividing both the gastrocolic and splenic ligaments.

The mobilized portion of the greater curvature of the stomach was then pulled to the right side in the direction of the underside of the left hepatic lobe using a 5-mm flexible grasper. By lifting the stomach, the liver was automatically pulled up. This retraction of the liver facilitated further exposure of the angle of His. It is important to identify and mobilize the angle of His with exposure of the left crus of the diaphragm to facilitate the complete resection of the fundus. Retrogastric adhesions were removed with the LigaSure device to allow for the complete mobilization of the stomach, to eliminate any redundant posterior wall of the sleeve and to exclude the fundus from the gastric sleeve.

Once the stomach was completely mobilized, a 36-French orogastric tube was inserted orally into the pylorus and placed against the lesser curvature. This calibrated the size of the gastric sleeve, prevented constriction at the gastroesophageal junction and provided a uniform shape to the entire stomach. Gastric transection was started at a point 6 cm proximal to the pylorus, leaving the antrum and preserving gastric emptying. A long laparoscopic reticulating 60-mm XL Endo-GIA stapler (Echelon Flex-Ethicon-Endosurgery) was fired consecutively along the length of the 36-French orogastric tube until the angle of His was reached. Two sequential golden 1.8-mm cartridges were used to staple the antrum, followed by three or four sequential blue 1.5-mm cartridges to staple the remaining gastric corpus and fundus. During such procedures, care must be taken not to narrow the stomach at the incisura angularis. It is important to inspect the stomach anteriorly and posteriorly to ensure that there is no redundant posterior stomach.

Approximately 80 % of the stomach was separated. The entire staple line was inspected for bleeding. Bleeding necessitated the prompt placement of clips along the line of bleeding. No intraoperative leak test was employed. Closed suction drains were routinely used. The resected stomach was extracted through the umbilical incision without a specimen endobag. The fascial defect was closed with 0/0 absorbable sutures.

An upper gastrointestinal (UGI) contrast-swallow study with Gastrographin® was performed on postoperative day 1 (Fig. 1), and if it was negative, the patient was put on liquid diet assumption for one more day. Patients were discharged once they were able to maintain hydration and manage pain with oral analgetics. Patients were routinely placed on a daily proton pump inhibitor for 1 month. A routine follow-up with attention to the electrolyte and vitamin levels was recommended every 6 months after surgery.

Fig. 1
figure 1

An UGI contrast swallow study was performed on postoperative day one

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Definition and diagnosis of leakage

The time of appearance of leaks was classified according to Csendes et al. [13], with leaks being detected early [postoperative day (POD) 1–3], intermediate (POD 4–7) or and late (POD ≥ 8) after surgery. Laboratory tests were routinely performed on the first POD and in cases with suspicious clinical symptoms, such as pain, discomfort, fever, tachycardia and tachypnea. An UGI series with Gastrographin® was performed routinely on POD one. After POD one, in cases with clinically suspected suture leakage, a computed tomographic (CT) scan was performed using a standard multi-slice technique with liquid contrast media.

Statistical analysis

The demographic data were prospectively collected in a digital database. The results are expressed as the medians (range). The statistical analyses were performed using the Graphpad Prism 5.0 software program (La Jolla, CA, USA).

Results

A total of 153 patients (119 female, 34 male) underwent sleeve gastrectomy at our institution during the study period. The median age was 46 years (range 19–73) and the median preoperative BMI was 42.3 kg/m2 (range 34.8–72.9). The median length of the operation was 86 min (range 48–140). Conversion to a conventional procedure was necessary in one patient (0.6 %) due to severe arterial bleeding. No intraoperative or postoperative deaths occurred.

Regarding the postoperative %EWL, patients were followed up 18.4 months after surgery. A distinct median EWL of 53.0 % was found. The median postoperative BMI was 33.3 kg/m2 (range 19.7–56.1 kg/m2). A postoperative BMI <22 kg/m2 was observed in one patient without evidence of abnormalities. The postoperative outcomes are noted in Table 2.

Table 2 Surgical outcomes
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Overall, there were eight severe postoperative complications (5.2 %). These included five cases of postoperative hemorrhage, which were detected by clinical symptoms (tachycardia of ≥100 beats/min, low blood pressure of <100/60 and decreased hemoglobin levels), and all cases were resolved by re-laparoscopy on POD one. The four patients in this group with abdominal drains showed no signs of any intra-abdominal bleeding in the drains. The subsequent postoperative course was uneventful, and these patients could all be discharged on POD 7.

Three patients developed stapler line leakage near the gastroesophageal junction, which were diagnosed on POD 3, 4 and 10. Interestingly, the usual postoperative UGI contrast-swallow studies with Gastrographin® on POD 1 were negative in all three patients. In addition, a repeated exam on POD 4 in one patient with staple-line leakage remained negative. The leaks were diagnosed solely by clinical symptoms (tachycardia ≥100 beats/min, pain VAS ≥5, fever ≥38.5 °C) and by CT scans after oral application of contrast media. All patients with leakage received broad-spectrum antibiotics.

One patient with leakage diagnosed on POD 3 underwent re-laparoscopy and abdominal lavage, and the area of the leak was mobilized and resected by a golden cartridge (Echelon Flex-Ethicon-Endosurgery). A drain was positioned and a covered self-expandable endoscopic stent was placed. The subsequent postoperative course was uneventful, and the patient could be discharged on POD 19 without further complications. The stent had to be removed prematurely on POD 36 because of a bolus-associated stent obstruction.

One patient with leakage diagnosed on POD 4 underwent re-laparoscopy, then relaparotomy and abdominal lavage, and the leak was oversewed with PDS 2.0 interrupted sutures, and two drains were positioned close to the leak. No endoscopic stent was placed because of logistical problems. A stent was not available and was ordered after the first operation. On POD 9 the patient developed leakage again. A second relaparotomy was performed with abdominal lavage, the leak was oversewed again with PDS 2.0 interrupted sutures and a covered self-expandable endoscopic stent was placed. The further course was complicated, and the patient was finally discharged on POD 63. The stent was removed on POD 146.

One patient with leakage diagnosed on POD 10 underwent gastroscopy, percutaneous drainage, and a covered self-expandable endoscopic stent was placed. The subsequent course was complicated, and the patient was finally discharged on POD 71. The stent was removed on POD 71.

Three patients (2 %) developed a severe gastroesophageal reflux disease and are still being treated conservatively.

The median postoperative hospital stay was 5.5 days (range 3–71 days). In this series, there were two statistical outliers, which were numerically distant from the rest of the data. Two patients with leakage had a hospital stay of 63 and 71 days.

Discussion

This study shows that SG is an effective and feasible procedure in bariatric surgery, with a %EWL of 57.2 % after a median follow-up of 18.4 months. There was no mortality, and the major complication rate was 5.2 %. The two most common complications after SG are staple-line bleeding and anastomotic leakage [14]. The American Society for Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee [15] statement quotes an overall complication rate for SG of 0–24 % and a mortality rate of 0.39 %.

The postoperative staple-line bleeding rate was 7.3 % in the study by Silecchia et al. [16] and leaks after SG are reported to occur in 1.4–5.3 % of cases [8, 17, 18]. The routine or selective use of postoperative diagnostic methods is controversial. Likewise, postoperative contrast-swallow tests and routine placement of closed suction drains have been advocated by several authors, whereas others claim that overtesting is unnecessary and that good clinical judgment suffices [10, 11, 14, 19–21].

Bariatric surgeons often use drains for several reasons: (1) to be quickly alerted to the presence of a leak, (2) to possibly obviate the need for an emergency re-operation by converting a leak into a controlled fistula, (3) to remove any excess irrigation fluid that may be contaminated and prone to abscess formation and (4) to aid in the diagnosis of intra-abdominal bleeding [19]. However, drains may cause more harm than simply being an inconvenience and irritation to patients. Randomized studies after gastrectomy have found no benefit of surgically placed closed suction drains [22, 23]. Therefore, normal drain output may give the managing team a false sense of security and bias the leading differential diagnosis inappropriately away from intra-abdominal pathology. We found that abdominal drains were not successful in diagnosing leaks or hemorrhage in our patients. In our study, the postoperative bleeding rate was 3.3 %: five patients developed significant postoperative bleeding with typical clinical signs of hemorrhage requiring re-laparoscopy. Interestingly, the intra-abdominal drains did not show bleedings prior to the diagnosis. After the re-operation, the usual subcutaneous application of low molecular weight heparin (60 mg enoxaparin) was discontinued for 24 h without any further bleeding complications.

Many institutions perform routine UGI contrast-swallow studies to evaluate patients for leaks or stenosis on POD 1 or 2. The sensitivity of UGI for leaks is very low. All of the patients in this study who developed a leak had an initial negative swallow study and required an additional CT scan with contrast swallow to identify the leak [24]. Not surprisingly, the most sensitive method for leak detection is a high index of suspicion. This is consistent with similar observations in numerous reports [8, 17–19]. Tachycardia, fever and abdominal pain are the most consistent signs for leakage in the described patient population. In general, laboratory examinations are rarely contributory, and as hinted earlier, contrast-swallow studies are notorious for showing “normal” results in the presence of leaks [20, 25]. In contrast, Jurowich et al. [26] and Triantafyllidis et al. [27] suggested that UGI radiography with contrast media and gastroscopy are comparable and superior to standard CT in patients with a BMI 50+ to detect leakage after SG. Otherwise, CT scans had the highest rate of leak detection and confirmed the clinical diagnosis [8, 17, 18, 24]. In our series, swallow tests were performed for all 153 patients on POD 1. Neither leakage nor outlet obstruction in the gastric tube was diagnosed, and all contrast-swallow studies showed “normal” postoperative results. This might have been due to an inflammatory component around the leak, and has been seen by others as well [17]. It is also logical to assume that most leakage occurs later than POD 1. The potential benefit of an early routine contrast swallow study seems to be very small compared with the costs of the study and the low incidence of leakage.

A recent systematic analysis showed that oversewing or buttressing of the staple line does not have a clinically significant effect on leakage [18]. However, Bellanger and Greenway [28] used a 34-Fr bougie without buttressing or oversewing of the staple line, and saw a leak rate of 0 % in 529 cases. A recent consensus statement by an international sleeve gastrectomy expert panel deemed the optimal bougie size to be 32–36 Fr [29]. Parikh et al. [30] analyzed 112 studies encompassing 9991 cases of SG. They found that buttressing did not impact the rate of leakage, but noted that utilizing a bougie ≥40 Fr may decrease leaks without impacting the %EWL for up to 3 years. Long-term studies are needed to definitively determine the effects of the bougie size on the weight loss after SG. We used a 36-Fr bougie without buttressing or oversewing of the staple line in our cases.

Gastric fistulas develop secondary to an impaired normal acute healing process. Local risk factors include impaired suture line healing, poor blood flow, infection and poor oxygenation with subsequent ischemia. Some authors have suggested that most fistulas are not due to staple failure, and consequently, staple-line dehiscence, but are due to ischemia in the gastric wall next to the staple line, which may be caused by dissection of the greater curvature when using the Ultracision® or LigaSure® systems [8]. Baker suggests that fistulas on the staple line may have multiple causes, but these can be divided into two categories: mechanical–tissular causes and ischemic causes. In both situations, the intraluminal pressure exceeds the tissue and suture line resistance, thus causing the fistula. Classic ischemic fistulas tend to appear between 5 and 6 days after surgery, when the wall healing process is between the inflammation phase and fibrotic phase. When the cause is mechanical–tissular, fistulas are usually discovered before this period, that is, within the first 2 days after surgery [31]. However, we believe that two of our three leaks (POD 3 and 4) may have been caused by thermal injury due to these devices.

In the First International Consensus Summit for Sleeve Gastrectomy, the treatment of leaks included early oversewing, drainage, endoscopic clipping, stents, creation of a Roux-loop and even total gastrectomy [10]. Fuks et al. found that, regardless of their experience, there was a significant risk of leakage in the super-obese patients. They observed seven leaks in 135 cases, six of which underwent reoperations, and all required reintervention and endoscopic stenting.

Endoscopically placed stents, combined with percutaneous drainage and a short duration of parenteral nutrition, usually provide a good outcome [32]. However, the treatment of leakage after SG is problematic. According to the recent literature and based on our experience, we recommend the following management algorithm for patients who have undergone SG with tachycardia, pain and fever. First, a CT swallow study should be performed. If this study demonstrates an abnormal finding (e.g., all intra-abdominal fluid collection should be considered to be a leakage), aggressive surgical management should be performed. To avoid overwhelming sepsis following the re-operation, debridement, lavage and drainage are useful. Closure of the defect can be attempted, but usually fails due to the poor tissue quality. After re-laparoscopy, stent placement is a good treatment option for leaks, because it can temporarily bypass the site of leakage at the gastroesophageal junction and allows enteral nutrition to be maintained until complete closure of the leak. Most authors recommend a period of 6–8 weeks as the optimal time to withdraw the stent [33]. Patients who do not respond to any of these procedures and those with persistent fistulas are candidates for two types of reintervention: conversion to Roux-en-Y gastric bypass or total gastrectomy [10, 17, 34, 35].

In conclusion, SG is an effective procedure that can be used to achieve significant short-term weight loss. According to the recent literature and based on our experience, the routine use of drains and UGI series on POD 1 is not necessary for the safe management of SG patients. Clinical signs and symptoms (tachycardia, pain, fever, hypotension) provide the best evidence of the presence of leakage or bleeding. An early diagnosis of these complications is the key to ensuring that adequate treatment with immediate re-laparoscopy can be provided.