Although gastric sleeve surgery is one of the safest bariatric procedures available, a gastric leak is one of the most feared post-surgical complications because it has the potential to become life-threatening. Fortunately, a leak occurring after sleeve gastrectomy is rare, occurring in maybe one out of 200 patients. Nevertheless, the benefits of undergoing sleeve gastrectomy far outweigh the risk.
What is Gastric Sleeve Leak?
A gastric leak occurs when a hole or gap develops somewhere along the staple line closure that your bariatric surgeon used to create the banana-like stomach pouch to help you eat less. This gap allows stomach juice to escape into the abdominal cavity, sometimes causing a severe infection to develop.
According to a study published by the Alexandria Journal of Medicine, the highest percentage of leaks occurred in patients who had laparoscopic gastric sleeve surgery. About 70% of patients who developed a leak after gastric sleeve surgery had the leak at the site where the esophagus meets the stomach.
Gastric leaks occur when the staples used to make the gastric pouch come apart or when your body doesn't heal properly and form a complete seal following obesity surgery. The reason leaks are so problematic is that gastric juices contain bacteria that can cause myriad health problems when they migrate outside of the gastrointestinal (GI) tract. Failure to detect and treat a leak in a timely manner can lead to:
- Gastric ulcers
- Fistulas, which are larger holes in the GI tract
- Infections that lead to sepsis and septic shock, injuring all body systems
- Multiple organ failure
Early diagnosis helps avoid complications, while a later diagnosis increases the risk and severity of possible complications.
Gastric sleeve leak symptoms vary from patient to patient. Some even fail to recognize them until they worsen. After undergoing bariatric surgery, be extra vigilant of your body as a day or two can make a decided difference in management. The most common symptom is abdominal pain and stomach and shoulder or chest pain, which increases with each passing day.
Gastric Sleeve Leak Symptoms
A general feeling that something is wrong is quite common, as is general discomfort. Tachycardia, or rapid heartbeat, is the first symptom in patients with an early leak, but fever presents first in those with intermediate and late leaks. Some patients are even asymptomatic, making the condition difficult to diagnose. You may also have one or more of the following symptoms:
- Abdominal pain, bloating or diarrhea
- Unexplained weight loss
- Nausea or vomiting
- Fluid leaking from an open wound in your abdomen
- Difficulty breathing with more than 18 breaths per minute
Clinical symptoms of a leak after gastric sleeve surgery include increased white blood cell count and C-reactive protein levels.
How is a Gastric Sleeve Leak Diagnosed?
Diagnosing a leak is further complicated by the fact that there is no single, reliable test resulting in a definitive diagnosis. Diagnosis is clinical, meaning your surgeon must consider all symptoms in relation to timing after gastric sleeve. Several imaging tests can indicate if a leak is probably:
- An upper endoscopy using a scope involving a flexible tube with a light and a camera to look at the inside of your esophagus and stomach
- An x-ray of your stomach using contrast liquid so that healthcare providers can more clearly see the area
- A fistulogram is an x-ray of a fistula that goes through your skin to the outside of your body that also uses contrast liquid injected into an open wound
- An ultrasound, CT, or MRI may be used to take pictures of your stomach and intestines to show the leak's source
If imaging tests do not show leaking but you still have symptoms, your doctor may advise emergency surgery.
Types of Gastric Sleeve Leaks
Gastric leaks are generally classified according to the time of their emergence:
- Early leak, appearing between Day 1 and 3 following surgery, encompassing 95% of leaks
- Intermediate leak, appearing between Days 4 to 7
- Late leak, developing during or after Day 8 after surgery
Bariatric surgeons also classify leaks according to their location or reason for development. They are also classified as clinical or sub-clinical, depending on their severity.
Can Gastric Sleeve Leak Occur After One Year?
About 99% of leaks are identified within 30 days after surgery, so approximately 4% to 5%
5 of patients can experience one after they return home. Most leaks are the result of suture line disruption, which is why they occur soon after surgery. However, in rare cases, the area of the stomach sewn together can begin to leak months or even years later.
All these aspects matter greatly because each type of leakage manifests its own set of symptoms and determines the appropriate action for its management.
What Causes a Stomach Leak after a Gastric Sleeve
Gastric leaks can be due to mechanical or ischemic causes, with the latter meaning the area where the leak occurs has an improper blood supply due to the obstruction of an artery. Misfiring of the stapler used to create the stomach tube or direct tissue injury during surgery are considered mechanical causes that usually appear within two days of the procedure. Ischemic causes usually appear five to six days post-op.
Who is at risk for a leak after sleeve gastrectomy?
The more obese you are before surgery, the higher your risk. Other factors include:
- Are male
- Have other health problems
- Prior abdominal surgery
Treatment of Gastric Sleeve Leak
Treatment of an early leak is generally easier than a delayed leak. Make sure you get the right help as soon as possible could mean the difference between gastric sleeve success and failure. Treatment depends on the cause and type of leak you have and can include:
- Antibiotics to treat or prevent a bacterial infection
- Nutritional support given through an IV or a tube in the small intestine to help you get the nutrients you need while your leak heals
- Negative pressure wound therapy (NPWT) for leaks that go outside your body, using a wound vacuum or pump to remove excess drainage from the wound and help pull the edges closer together
Emergency surgery is the quickest way to treat an early leak as it washes out the infection and seals the hole in the stomach pouch. The American Society of Metabolic and Bariatric Surgery (ASMBS) indicates that surgical options differ between acute leaks ongoing for less than five days and chronic leaks, present for four weeks or more. For acute leaks, the main surgical goal is to drain the leaking fluid to avoid infection. The ASMBS recommends nonoperative management in chronic leaks, although some surgeons may advise converting to gastric bypass surgery.
How to Avoid Leaks and Lower Future Risks
Research has indicated that surgeons who construct gastric sleeves around a Bougie dilator, which is used to size the stomach during sleeve gastrectomy using a larger size stomach pouch may be safer for patients, even though they may lose weight at a slower pace.
However, there are a few things you can do to avoid a leak after surgery:
- Truly rest following surgery to give your body the rest it needs
- Comply with post-operative instructions, taking all prescribed medications
- Commit to your post-operative diet and stick with liquids for as long as your nutritionist recommends as eating solids too soon can cause complications
- Notify your doctor immediately of any symptoms
- Attend all post-operative and follow-up consultations to monitor risks
- Avoid NSAIDs as they can cause ulcers and other complications
Steps Your Doctor Should Take to Avoid a Gastric Leak
Your bariatric team should take proper measures to prevent leaks in patients. Eligibility for bariatric surgery depends on your body mass index and any related comorbidities. Relating your previous clinical history is essential as it can prevent complications.
Ask your surgeon if he reinforces the staple line with sutures to reduce the incidence of leaks. Testing for leaks, during surgery and after surgery before you leave the hospital will allow your medical team to treat a leak immediately. Frequent patient monitoring is imperative, which is why you should comply with follow-up consultations, even if you feel okay. This is the best way to prevent a gastric sleeve leak.