Stage dependent management of sleeve gastrectomy leaks - a systematic review with proposed classification and management algorithm

Aim: Gastric leak following foregut surgery remains a major challenge to clinicians. Treatment algorithms may vary between institutions often depending on clinician preference. The objective of this review is to assess the efficacy of different treatment strategies (i.e., endoscopic and surgical) for sleeve gastrectomy leaks across the literature, share our own centre’s experiences and attempt to implement an algorithm in managing sleeve leaks according to their severity as classified by a computed tomography-based staging system. Methods: A comprehensive search of existing literature over the last decade was conducted using pre-defined criteria in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Sleeve gastrectomy leaks in the included studies were further categorized according to severity, prior to analysing the efficacy of treatment methods. Results: Following review of 1,109 potential articles, 36 studies were included, involving a total of 1,246 sleeve leak patients. The mean age and body mass index of patients ranged from 33 to 46 years of age and 37 to 48 kg/m², respectively. In type 1-2 leaks, surgical or radiological drainage followed by primary endoscopic therapy (i.e., stenting, internal drainage, over the scope clips, fibrin glue and/or E-VAC) was effective (leak resolution rates - 50%-100% between reporting papers). Endoscopic therapy remains a viable treatment option in treating type 3-4 leaks with success rates ranging from 33%-95%, although surgery (i.e., fistulo-jejunostomy, Roux-en-Y gastric bypass or total gastrectomy) may be required in chronic leaks where all other modalities have failed. Conclusion: Management of sleeve leaks should be driven by the underlying leak pathophysiology. Defining variables such as the size of the defect, size of any abscess/collection and presence of a stenosis can allow differing options to be applied. Patients who fail to respond appropriately can be escalated to alternate therapies with the aim of resuming per oral nutrition and minimizing inpatient stay.