Almost all people (with the exception of some bariatric surgeons) believe that the sleeve gastrectomy is a safer operation than the gastric bypass because of the ease and simplicity of the procedure, as also the possibility of leaks in the latter case (multiple staple lines). At the root of the confidence of many surgeons is the view that the stomach, being a vascular organ, would be a safe bet in healing.
This is an oversimplification, IMO.
I have mentioned before that the sleeve, in spite of being an easier and faster procedure, may be more problematic in terms of leak alone. The leak rate of the sleeve is around 2-3 percent, while that of the bypass is around the same, but the leaks behave differently.
The sleeve leak (as discussed in details before) is a high pressure leak, occurring usually at the angle of His, and tends to persist unless stented.
The bypass leak occurs at multiple possible sites, half in the gastrojejunostomy, but being a low pressure leak, tends to dry out on its own once the surgical re-exploration is done and issues sorted out.
(pic from referenced article)
Leaks after a bypass are usually detected on Day 3, give or take some. The detection may be because of routine dye study, but usually the patient already has a high pulse rate, fever, abdominal pain, dirty drain output, etc. It is important to remember that around a third of patients may have no clear evidence of a leak in spite of CT scan or dye test or both. In fact, in an older study, only a pulse rate over 120 and a rapid breathing rate were consistent in patients with leaks, and only 2 out of 9 leaks showed up on the dye study. This means that a laparoscopic re-exploration is the most reliable of investigations for a leak!
Upon detection of a leak after the bypass, the patients is usually re-explored laparoscopically. The procedure may include any or all of the following:
- Re-suture of leak with omental graft
- Re-do the full anastomosis
- Partial remnant gastrectomy (in case of remnant staple line leak)
- Drainage
- Gastrostomy
While around 2 percent of bypasses may leak, when they do occur, they inflict considerable collateral damage: gastrogastric fistula, wound complications, lung problems, DVT/PE, etc.
It is also important to remember that a downstream problem like an obstruction of the jejunum may cause leaks from the staple line above.
Are there groups which have a predictably higher leak rate?
Yes, it may be said that the leak risks are higher in:
- Revisional bariatric surgeries (around 13-14%)
- Males.
- Higher BMI.
- Multiple co-morbidities.
- Patients with previous abdominal operations.
- Circular stapled anastomoses (hand-sewn method has the lowest leak rate of 0.4%): controversial!
- Inexperienced surgical hands.
- Those who have had an intraoperative mishap (colon/splenic injury, for example).
- One leak may predispose to another.
- Buttressed staple lines may have an advantage in leak rates.
The mortality of jejuno-jejunal leaks is close to 40-50 percent, while a GJ leak has a 10% mortality.
What happens once a leak is detected and the patient re-explored? Initial days may be stormy or tense, spent in the ITU with ventilatory support given to some patients (remember, many of these patients are already sick with other co-morbidities), and then the sepsis gets controlled and the nutrition support started (through the gastrostomy tube or through a central vein in the neck, etc.). The patient recovers slowly and the leak heals with time. In the rare case, if a leak persists beyond a month, a stent may be required.
With this post, our continuing exploration of the Achilles heel of all bariatric operations has been, you will admit, rather thorough. If this and the other articles frighten you, then be assured that this was and is not the goal of my writing. We at BMI believe that an informed patient is the best one, and we owe it to you to even out the information asymmetry in this highly technical branch of medical care. All surgeries have side effects, but they occur in a small minority of patients. In the given case, each complication hits hard, and a prepared patient handles it better. As bariatric surgeons, we need to brief you adequately as to the possible downsides of what is otherwise a transformational event in life.
Ref:
Diagnosis and Contemporary Management of Anastomotic Leaks after Gastric Bypass for Obesity
J Am Coll Surg
Rodrigo Gonzalez, MD, Michael G Sarr, MD, FACS, C Daniel Smith, MD, FACS, Mercedeh Baghai, MD, Michael Kendrick, MD, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS, Michel M Murr, MD, FACS
