Management of a Series of Staple Line Leaks Post Sleeve Gastrectomy: Experience of a Bariatric Surgery Center of a Series of Staple Line Leaks Post Sleeve

Gabriele De Sena2*, Alfredo Allaria1, Giovanni Giordano1, Danilo Porpora2, Rosa D’Amico2, Vincenza Capuozzo3, Francesca Romana Ciorra4, Gianmarco Ascolese2, Flavia D’Apice2 and Vincenzo Napolitano1 1Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Italy 2Integrated Assistential Department of General and Special Surgery, University of Campania Luigi Vanvitelli, Italy 3Department of Surgery, “Santa Maria della Pietà” Hospital, Italy 4Emergency and Acceptance Department, AORN Cardarelli, Italy


Introduction
The purpose of this analysis is to identify a therapeutic algorithm in case of Staple Line Leack (SLL) after Laparoscopic Sleeve Gastrectomy (LSG) based on the evidence present in the literature and our clinical experience. Sleeve gastrectomy (LSG) is a surgery procedure practiced to treat morbigena obesity. The anthropo-pylon region and the vassal innervation remain intact.
SLL is the most worrying and potentially deadly complications of this procedure. A leak is defined as leaking gastrointestinal content through a continuous solution of the sleeve suture line, which can freely carry itself into the peritoneal cavity or gather next to the suture [5,6]. SLL can be classified based on the time of appearance of the SLL, site, clinical presentation [1,4,7].
Based on the timing Regimbeau [8] classify SLL as:

a)
Early (appearance within the first week) b) Late (appearing after the first week).
Based on the site of dehiscence:

Data
We report a series of patients who presented SLL after LSG among 296 patients undergoing LSG between January, 2008 and January, 2017 at our operations unit. Patients who had undergone other bariatric surgery before LSG were excluded. The following data were collected: epidemiological characteristics, comorbidity, timing of the appearance of SLL in relation to LSG, the symptomatological framework of onset, the instrumental examinations performed.
Among the patients analyzed, 5 (1.65%) were lost at the follow-up and 9 had a SLL (3.04%):  (Figure 1). In one case the diagnosis was made by means of routine radiological control, without having specific symptoms and/or signs. A multidisciplinary approach was used for all patients, including fasting, total parenteral nutrition and antibiotic therapy.    In two cases, instead, it was necessary to remove the stent for dislocation of the same and reappeared hyperpiressia and a new perigatric collection. In these caseses, a transgastric drainage with double pigtails was realized at the same time. In one patient, transgastric drainage was used as the initial and only treatment.
In these three cases two transgastrial endoprosthetics were placed at the leakage point, two double pygmies with a diameter of 8.5 fz and length 3 cm. The patients were fed for two weeks through an enteric nose tube then they gradually resumed oral feeding. After 90 days the CT scan showed that the prostheses were no longer on site and there were no more signs of SLL. One of them at the CT check at 3 months still had one of the double pigtails in place so it was necessary to remove it endoscopically ( Table 2). Probably the leaks of the upper portion of the suture line have a multifactorial etiology. Some AAs have formulated the mechanistic theory that a suture too close to the esophagus-gastric junction and/or abdominal esophagus results in increased tension on the suture line and is this tension according to this theory causing the increased incidence of SLL in this area [14]. A second theory is that so called vascular, according to it the section of the gastric bottom would determine a relative ischemia at the expense of a critical area of the next portion of the suture line that would increase the risk of SLL [15]. Basso, et al. [16] describe well the spraying of this area indicating its critical issues. proposed by many AAs that avoids the critical area, it is obtained by leaving a gastric residue of 1-2 cm precisely at the level of the gastroesophageal junction [17]. A further theory sees as the cause of stenosis at the level of angular incisura in fact Yehoshua, et al. [18] has shown that high intraluminal pressure and low compliance of the gastric tube (situation that is determined when there is a stenosis to aungulus) can be the cause of leaks. There are also, described in the literature, numerous factors related to the patient that relate to a higher incidence of leaks. They are advanced age, BMI> 60 kg/m 2 , malnutrition and history of gastric bandage. The typical ischemic SLL appears between the fifth and sixth days after LSG, when the healing process of the gastric wall is between the inflammatory and fibrotic phase. When the cause is mechanicaltissue fistulas usually occur before this period, in the first and second days [19].

Diagnosis
Early diagnosis is critical for therapy. Tachycardia  Leak management depends on the patient's clinical condition.
The surgeon handling the complication must have a clear strategic algorithm based on the patient's condition, leak duration and available resources [23,24]. .

Discussion
The number of LSG has grown enormously in recent years.
Today LSG is the most practiced bariatric surgery in the world [2,25]. Despite this, managing some of the LSG complications still appears to be a challenging challenge for the surgeon. SLL is one of these fearsome complications [7]. It is known from the literature that the SLL of the proximal portion of the suture line has a much greater incidence and our data agree. The incidence of post-LSG SLL varies from 2.4% to 7% depending on the case [8][9][10]. In our analysis the incidence was 3.1%. Some surgeons believe that the suggitto can, by reinforcing the suture, reduce the incidence of SLL.
From the analysis of our data no patients had been overtyped and therefore we cannot make a comparison. Many studies exist on the use of bovine pericaryum membranes to reinforce the suture line, some authors believe that these significantly reduce the incidence of SLL in fact there is no agreement on this [26]. For the patients included in our study, bovine pericartion reinforcement was used, we believe that these devices can reduce the incidence of bleeding but have no influence on the sealing of the suture [27]. The treatment of SLL is multidisciplinary and requires the commitment of medical, radiological, endoscopic and surgical procedures as well as the use of innovative and/or biotechnological technologies [28].
Surgery in case of SLL, generally conducted with laparoscopic method, has two fundamental indications:

2) Appearance of sepsis and MOF
The purposes are:

3) Pack a digiunostomy.
In our case study it was necessary to carry out only one resurgery for a late SLL in which signs and symptoms of sepsis appeared, a washing of the abdominal cavity was carried out and the packaged an effective external drainage, the intervention was conducted in laparoscopy [29]. Radiological percutaneous drainage is generally indicated in late SLL cases to drain the perigatric collection and take purulent material for coltural examination.
It is a temporary measure pending endoscopic treatment. In the cases that we considered, in 4 patients with late SLL was placed the CT drainage guided before the placement of the megastent it allowed Currently, megastent treatment is the most practiced endoscopic approach. However, its use is discussed due to low patient tolerance and migration risk ranging from 33% to 88%. In recent times some authors (Peguignot, et al.) [30] consider treatment with first choice double pigtail, they believe that this procedure is more effective, better tolerated and results in faster healing when compared to the stent. On the contrary, it is believed that, for the purposes of healing, rather than bypassing the leak site it is more important to achieve an effective drainage of all perigatric collections. Therefore, many AA have abandoned the stent and propose the use of transgastric dredging with double pigtail as a first choice treatment of SLL.

Conclusion
SLL is LSG's most frequent and fearsome complication and its exclusively surgical treatment has proved to be a challenging challenge for the bariatric surgeon [10,31]. We believe, and in this we are supported by numerous works present in the literature, that the treatment of SLL must avail itself of the skills of other specialties such as radiology, endoscopy, engineering, etc. [32]. According to scientific literature and our experience we [32,33] have developed our own decision-making algorithm based on our data and the evidence in the literature. We distinguish two therapeutic pathways based on two clinical frameworks present: stable patient, nonstable patient.

Stable Patient
in case of localized peritonitis, but not the signs and symptoms of sepsis there is no indication of re-intervention [34]. The treatment will consist in the placement of an endoprosthesis: a megastent with the realization of a guided CT external drainage or one or more double pigtails to achieve an in addition transgastric drainage there will be an enteral nose tube for nutrition. Both procedures aim to complete the drainage of the harvest, stimulate healing for second intention and allow a rapid resumption of oral nutrition.

Unstable Patient
there are signs and symptoms of sepsis, there is widespread peritonitis and there may be an interest in the median. In these patients is indicated the surgery of drainage and washing of the abdominal cavity, a fasting can be packaged, if necessary, a pulmonary lobectomy can be carried out. Once stabilized to the patient will be placed a transgastric drainage (one or more double pigtails) which has the function of promoting healing and helping to further drain the collection the treatment also includes an entral nose tube for one feed the patient. In conclusion, we can say that that of SLL is a minimally invasive and conservative treatment possible thanks to a modern multidisciplinary approach.

Note 1. Megastent
It is a prosthesis placed in an endoscopic procedure that is performed under general anesthesia (Figures 3 & 4), it aims to create a physical barrier to the leakage of gastric material through the leackage point through the placement of a tubular prosthesis [35].
The prosthesis used is a generally a egastent with the following characteristics: 1) Soft and flexible body that adapts to the anatomy of the tabulated neostomac.
2) Sufficient diameter and length to ensure that the extrudalal is located at the middle third of the esophagus and the distal extremity to the ladenum or trans pylon to the first duodenal portion.
3) The stent is completely covered with silicone so it can be removed with extreme simplicity and has a second metal mesh that soon anchors it even more and reduces the risk of migration.  The device is left on site for at least four weeks, but no later than six for the risk of tissue hyperplasia that would hesitate in greater difficulty during removal. Prosthesis often induces nausea, vomiting and restrosternal pain especially in the early hours and early days so much that it is little tolerated by patients [36]. There is a risk of migration and relocation that varies from 18% to 33% depending on the case [18,37].

Note 2. Transgastric Drainage
It is a prosthesis placed in endoscopic procedure conducted under general anesthesia that consists in the placement of one or two small transgastric drainages in the shape of double pigtails ( Figure 5) through the continuous solution of the suture line to obtain a drainage to the gastric cavity (at less pressure) of the spilled material and thus stimulate healing for second intention. It can be associated with the simultaneous placement of an enteral nose snooze for enteral nutrition. The patient will be able to resume the diet for about 15 days after the procedure. Usually after a few months the small prosthesis relocates and is expelled with feces, its removal therefore only rarely requires a new endoscopy [30].