Texas Tech University Health Sciences Center Lubbock, Texas
Introduction: Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss surgery. LSG staple line leak occurs in 0.1% of patients. We present a case of LSG leak successfully managed with OverstitchTM endoscopic suturing system (OESS) and esophageal stent (ES) placement.
Case Description/Methods: A 54-year-old man with HTN, DM and morbid obesity with one week status post LSG performed in a neighboring country presented to emergency room with diffuse abdominal pain, nausea, vomiting, and constipation since surgery. His BP was 106/72mmHg, HR was 125bpm, T was 97.8 F, WBC was 19.04 k/ul, and Hb was13.6 g/dL. CT abdomen showed large intraabdominal fluid collections. An LSG staple line leak was suspected. An NG tube was placed for decompression, antibiotics were begun, and he was taken for urgent diagnostic laparoscopy revealing large amount of intraperitoneal serosanguinous fluid. Gastric leak was confirmed, and multiple abdominal and pelvic drains were placed. Significant friable tissues prevented surgical repair of the leak. Total parenteral nutrition (TPN) was started. A week later GI service was consulted. EGD showed a 20 mm perforation along LSG staple line located 3cm below gastroesophageal junction (GEJ). Using OESS the defect was successfully closed followed by placement of a 23mmx155mm fully covered ES. Upper GI series (UGI) along with per oral methylene blue administration excluded leak. Naso-jejunal (NJ) feeding was then started and TPN was weaned off. Patient did well and discharged home. ES was removed at a follow up EGD in five weeks, and 2-3mm residual LSG staple line defect without contrast extravasation was identified and endoscopic suturing was repeated. NJ feeding was continued. UGI in 1 week showed no leak. NJ feeding was discontinued, and oral feeding was begun. Patient has been doing well since on subsequent follow up in the clinic.
Discussion: LSG is a popular bariatric procedure due to its simplicity and efficacy. But LSG leak can be fatal if not managed appropriately. Prompt surgical measures are the key steps. In unusually complicated cases as ours, multidisciplinary management brings a favorable outcome. Endoscopic closure of the LSG defect can be vital in source control when surgical measures fail. The success of endoscopic therapy depends on leak onset, with healing achieved in about 48.5% at one month to 73.6% at 6 months. In our case, OESS coupled with covered esophageal stent placement completely healed a large LSG defect.
