The most common complications in sleeve gastrectomy are staple line fistula, (secondary) bleeding and abscess formation.
Secondary bleeding (up to 8%):
Bleeding sources may be extraluminal and intraluminal.
Symptoms: Hb drop; hypotension; tachycardia; free fluid; hematemesis; melena
Causes: Secondary bleeding from the staple line is the most common cause of bleeding -> laparoscopic hemostasis by oversewing or clipping; if necessary, fashion new staple line.
There is no consensus on whether bleeding from the staple line can be prevented by reinforcing the staple line.
Other bleeding possibilities include the short gastric vessels and the resected branches of the gastroepiploic vessels along the large curvature, as well as splenic lacerations.
Unlike in gastric bypass, it should be possible to access endoscopically all endoluminal sources of bleeding, such as ulceration in the gastric sleeve.
If endoscopy cannot stop the bleeding -> perform redo laparoscopy. If laparoscopic overview cannot be obtained, convert immediately to open surgery.
Options if the source of bleeding cannot be visualized: Contrast enhanced CT, interventional radiology coiling if the location is suitable.
Staple line failure (up to 5.1%):
In patients with morbid obesity these complications pose a particular risk associated with a high mortality rate.
Early leakage:
- Clinical signs: Tachycardia; abdominal pain; hypotension; elevated inflammatory markers; fever; new onset shoulder pain.
- Often, tachycardia is the only symptom. Any tachycardia (HF > 120 bpm) is grounds to consider redo laparoscopy/laparotomy.
- Relaparoscopy immediately after the initial laparoscopic procedure has a good chance of success. Ensure adequate drainage of perigastric fluid collections; in proximal locations local irrigation and placement of a target drain; for distal locations, also oversew the leakage site
- Alternatively, interventional radiology drainage of perigastric fluid collections
- Antibiotic regimen is mandatory.
- Late leakage (fistulas and abscesses) (1-3%):
- (>8 days) most common (73%), usually arising after patient has been discharged, often manifesting as fistula or abscess. Onset of chronic fistulas usually concomitant with stenosis, with increased intragastric pressure contributing to fistula persistence.
- 90% of leaks arise in the proximal part of the staple line.
Endoscopic techniques with concomitant drainage of extraluminal obstruction preferred.
- Stent placement: long, covered stent, maximum treatment duration six weeks.
- “Over the scope” clips (OTS): only for small, clearly visible defects, active removal of the clip is not possible.
- Endoluminal negative pressure wound therapy (Esosponge), in which the polyurethane sponge is placed directly into the abscess cavity located next to the gastric sleeve leak.
In far proximal refractory leakage, surgical conversion to a Roux-en-Y gastric bypass, thereby converting the high-pressure system to a low-pressure system.
Last resort: Gastrectomy—with high mortality rate
Stricture/stenosis (2.1%):
Most often at the angular incisure (88%) and esophagogastric junction (12%).
Causes: Staple line torsion; nasogastric bougie <40 Fr; healed ulcers; leakage site/fistula healed by second intention.
Management:
- Endoscopic balloon dilation in short proximal stenosis
- Insertion of a self-expanding stent; regular check of stent position in case of possible migration
- Conversion to Roux-en-Y gastric bypass in long stenosis
Ulcers:
Unlike in gastric bypass, ulcers are rare. Any preoperative history of ulcers must be assessed in detail (helicobacter pylori, gastrin) to prevent postoperative anastomotic ulcers. Ulcers may progress to penetration and perforation.
- Risk factors/causes: foreign body reactions; microleaks; local ischemia; peptic lesions with increased acid production in the gastric sleeve; untreated helicobacter pylori infections; nicotine abuse, herpes infection; and NSAID abuse
- Healing can usually be achieved with medication. General ulcer management with elimination of risk factors, e.g., cessation of nicotine and NSAIDs, PPI drug therapy.
- In the event of bleeding, institute standard endoscopic techniques.
- Perforated ulcers constitute an emergency and are oversewn and drained.
- Untreated ulcers may result in stenosis and dysphagia.
- Refractory ulcers are an indication for surgical revision.
Dumping syndrome (33%–45%):
With the preserved pylorus the risk is lower than in gastric bypass.
Dumping syndrome is a complex of symptoms physiologically resulting from abrupt emptying of the stomach with consecutive rapid exposure of the small intestine to undigested food.
Dumping syndrome ranges from mild gastrointestinal symptoms through vasomotor abnormalities to severe refractory hypoglycemia.
Early dumping (10–30 min after food intake) results in nonphysiologic high influx of interstitial fluid into the intestinal lumen due to the hyperosmolar chyme, leading to the distension of the intestinal wall and vasomotor pathology.
Late dumping (1–3 hours after food intake) results from too rapid absorption of water-soluble carbohydrates, leading initially to hyperglycemia followed by a counterregulatory, often overshooting, insulin response with hypoglycemia and its typical symptoms.
Management:
- Dietary measures
- Medication: Arcabose; somatostatin analogues, e.g., octreotide 3–4 times daily 50–100 μg s.c.
- Surgical measures such as pancreatic resection reserved for special refractory cases.
Treatment failure/inability to reach the treatment goal:inadequate weight loss/new weight gain (BMI > 35 kg/m2)
Management:
There are many options ranging from refashioning of gastric sleeve in sleeve dilation through repeat tangential gastric resection, to restoring restriction, and conversion to any bypass type.
Reflux:
In SG relevant rates of new onset reflux disease or worsening of preexisting reflux may require conversion or redo surgery.
