Staple Line and Anastomotic Leaks

Staple line and anastomotic leaks are feared complications for a bariatric surgeon and devastating for the patient. Early recognition and management are key to minimize morbidity and possibly mortality for the patient. The first clinical sign is tachycardia possibly accompanying respiratory distress, worsening abdominal pain, and sepsis. Prompt imaging with oral contrast can identify the presence of a leak, localize the affected area, and examine its containment. Despite similar clinical presentations, the etiology of sleeve gastrectomy staple leaks and anastomotic leaks differ. Sleeve staple leaks derive more from a combination of the physiology of a high-pressure system exacerbating a relatively ischemic location. Whereas anastomotic leaks are more grounded in general surgical principles such as tissue perfusion and tension. Combining the information from the patient’s clinical status, timing of the leak from the operation, imaging findings, and foundational knowledge of pathophysiology, management ranges from nonoperative, endoscopic, and operative approaches. Finally, operative techniques have been developed to prevent the formation of leaks. Current evidence shows a decreased leak rate in surgeons who have accomplished their learning curve for these operations. For sleeve gastrectomy, evidence currently supports the importance of the appropriate selection of staple-load thickness and the use of staple-line reinforcement. However, the data are mixed and the benefit has not fully been established. In Roux-en-Y gastric bypasses, there were no differences in leak rates between stapled versus hand-sewn anastomoses.