Diagnosis and treatment of the early gastric leak after sleeve gastrectomy in morbid obesity (clinical case)

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Introduction

Obesity remains a widespread medical and social problem today. In recent years, most countries around the world have seen a clear trend toward an increase in the number of not only adults who are overweight or obese, but also children and adolescents. According to estimates by experts from the World Obesity Federation, the prevalence of obesity will reach about 17% by 2025 and by 2035, it is forecasted to exceed 20%. In the Russian Federation, this indicator also continues to increase among both men and women, reaching 27.9% and 31.8% respectively in 2017 [1].

Bariatric surgery is currently considered the most effective treatment for obesity and related diseases such as type 2 diabetes, hypertension, obstructive sleep apnea, and non-alcoholic fatty liver disease. There are several types of surgery, with laparoscopic sleeve gastrectomy remaining the most popular and reproducible of them [2–4].

Even though it's simple to do and safe, there's a risk of post-op complications in sleeve gastrectomy (bleeding, suture line failure, stenosis, gastroesophageal reflux, etc.). Staple line leakage after laparoscopic sleeve gastrectomy is one of the most common early postoperative complications [5; 6]. However, there is no universal treatment algorithm, and some questions regarding the management of such patients remain unresolved. We present our own clinical observation demonstrating the diagnosis and treatment of early staple line leakage after laparoscopic sleeve gastrectomy.

The aim of the study is to demonstrate the diagnosis and author's tactics for treating early staple line leakage after laparoscopic sleeve gastrectomy.

Clinical Case

A 34-year-old female patient, Ms. G., came to the clinic with WHO grade III obesity (height – 173 cm, weight – 120 kg, BMI – 40kg/m²). Hypertension stage 2, grade II arterial hypertension, risk 3, and chronic calculous cholecystitis were diagnosed as obesity-related pathological conditions. The medical history indicates that she has been overweight since the age of 20 and has attempted to lose weight through various diets, but has been unsuccessful. After a preoperative examination on May 2, 2023, a laparoscopic sleeve gastrectomy was performed using a 36 Fr calibration probe and an Echelon 60 device (two green, one yellow, and three blue cassettes). The stapler line was not reinforced. During the first day after the operation, she had no complaints, her general condition was assessed as satisfactory, and her fluid intake was 200 ml. On the second day after the operation, she began to experience aching pain in the upper abdomen, but there was no tachycardia or peritoneal symptoms, and her body temperature remained normal. The patient was walking, drinking water, had a gas release, and had a single bowel movement. An ultrasound was performed, which revealed no fluid accumulation in the abdominal cavity. A multi-position X-ray examination of the esophagus and stomach with water-soluble contrast showed that the contrast medium was passing normally, with no leakage outside the organs (Fig. 1).

 

Fig. 1. X-ray examination of the stomach with water-soluble contrast in the frontal (a) and lateral (b) projections, in a standing position. No evidence of leakage beyond the contours of the stomach was found

 

However, the following day, neutrophilic leukocytosis was recorded: leukocytes 19.41 · 10⁹/L (reference range: 4.5–11.0), neutrophils 18.8 · 10⁹/L (reference range: 1.56–6.13), lymphocytes 0.31 · 10⁹/L (reference range: 1.18–3.74), monocytes 0.3 · 10⁹/L (reference range: 0.4–1.1), and an increase in CRP to 85mg/mL (reference range: 0–5), which led to a computed tomography (CT) scan of the abdominal cavity with oral and intravenous contrast. A distinct accumulation of fluid measuring 7.5 × 6 × 11 cm was found in the subdiaphragmatic space on the left near the cardiaс orifice, with traces of contrast medium, indicating staple line leakage in the cardia region of the gastric remnant (Fig. 2).

 

Fig. 2. Multispiral computed tomography of the abdominal cavity with intravenous and oral contrast. Frontal MPR reconstruction. Defect in the area of the staple line (green arrow) with contrast enhancement in the left subdiaphragmatic space (red arrow) and contrast medium leakage into a distinct fluid collection (blue arrow)

 

On May 5, 2023, the female patient underwent relaparoscopy. The abdominal cavity contained cloudy serous effusion, loops of intestine of normal color, without fibrin coating. The site of the staple line leakage in the stomach could not be visualized. An abscess with a volume of approximately 50 ml was found and opened in the area of the suspected failure, and a tube drain was placed in the cavity. Drains were also placed in the small pelvis and suprahepatic space. Antibiotic therapy with reserve drugs was prescribed: meropenem (1 g three times a day) and vancomycin (1 g twice a day) intravenously. During the first day after relaparoscopy, the patient was activated and received parenteral nutrition. Drainage from the abscess cavity ceased on the second day, there was no hyperthermia or intestinal paresis, but leukocytosis persisted at 16.5 · 10⁹/L, an increase in CRP to 192 mg/L and procalcitonin to 1.8 ng/mL (reference values: up to 0.5). A drinking test with water was performed, as well as an X-ray examination of the stomach and a CT scan of the abdominal cavity. During the X-ray examination, contrast passage through the esophagus and stomach was preserved, and no leaks were detected (Fig. 3).

 

Fig. 3. Control X-ray examination of the stomach with water-soluble contrast in a direct projection, in a standing position (a) and lying down (b). No data on contrast discharge was obtained

 

However, during CT (after X-ray examination) with the patient lying on her back, the previously identified abscess cavity remained without any tendency to decrease in size (Fig. 4).

 

Fig. 4. Follow-up multispiral computed tomography of the abdominal cavity with oral contrast. Axial plane. Contrast agent continues to be deposited in the previously visualized fistulous tract (red arrow) near the inserted drain (green arrow), with contrast enhancement of the cavity lumen (blue arrow)

 

The drain placed during relaparoscopy was removed, and percutaneous drainage of the cavity was performed under ultrasound guidance. Antibiotic, antiulcer, and infusion therapy were continued, as well as daily sanitation of the abscess cavity. The patient was allowed to drink in an upright position. During treatment, no temperature reaction was observed, and bowel function was not impaired (daily bowel movements). On the 14th day after relaparoscopy, an examination was performed (abdominal ultrasound, stomach X-ray, and fistulography), according to the results of which a significant reduction in the size of the cavity and insignificant contrast retention in the gastric remnant were noted during fistulography (Fig. 5).

 

Fig. 5. Fluoroscopic fistulography in the supine position in the straight projection (a). There is a decrease in the previously visualized cavity with the presence of a fistulous passage and contrast injection into the esophageal lumen (b – lateral projection, blue arrow)

 

Normalization of clinical blood test results and CRP levels was also noted. The patient was discharged for outpatient treatment with recommendations for oral intake of liquid food and drainage care. Two weeks later, a follow-up fistulography showed no contrast in the previously detected passage to the gastric remnant (Fig. 6).

 

Fig. 6. Follow-up fluoroscopic fistulography. Reduction in cavity size with no contrast enhancement of the previously visualized fistula. No communication with the stomach detected

 

The drain was removed. During a follow-up fiberoptic gastroduodenoscopy one month later, no defect was found along the edge of the staple line, including during insufflation.

Results and Discussion

The incidence of staple line leakage after longitudinal gastric resection varies widely and, according to some authors, can reach 16%, although on average it does not exceed 2.2–3% [5;7; 8]. In our clinic, out of 87 patients who underwent surgery, we encountered this complication for the first time.

The diagnosis, treatment strategy, and success of treatment for this serious complication depend on a number of factors, the most significant of which are the time of diagnosis, the nature of clinical manifestations, and the location and extent of the obstruction [9; 10]. After analyzing the literature and the experience of our colleagues from clinics in Russia, we have come to the conclusion that there is currently no generally accepted protocol for managing patients with staple line leackage after longitudinal gastric resection, although certain recommendations regarding key aspects of diagnosis and treatment are widely recognized.

According to gastroscopy data, staple line leakage is detected in only 28–50% of cases [2;11]. No leakage of contrast medium beyond the stomach was observed in our observation during multi-position X-ray examination performed both after primary surgery and after relaparoscopy. Similar data on the low effectiveness of gastric radiography are reflected in the works of A.G. Khitaryan et al. [12], L.P. Kotelnikova et al [13]. Therefore, at present, CT with oral and/or intravenous contrast administration should be considered the most valuable non-invasive method for diagnosing staple line leackage, as confirmed by the case we describe and data from the literature indicating 86–90% informativeness [14].

Не вызывает сомнений тот The fact is that in cases of early failure, surgery involving abdominal cavity sanitation and drainage is indicated, but the question of surgical access and defect suturing is disputable. We adhere to the position expressed in the presented observation that laparoscopic access allows for a complete revision, adequate sanitation, and drainage of the abdominal cavity and acute fluid accumulations, and that there is no need to use laparotomy for these purposes [10]. Some authors express the opinion that in cases of early failure, 2–4 programmatic relaparoscopies are necessary [15]. We believe that repeated laparoscopic repairs are only necessary in cases of inadequate drainage placement, as confirmed by clinical data and radiological diagnostic methods. As for mandatory visualization and suturing of the defect, we do not share this opinion not only in relation to early, but also to intermediate and late suture line failure, due to the impossibility of reliably visualize the defect in most cases, and when detected, to suture it completely due to the suture material cutting through the tissues as a result of their inflammatory changes.

A complete ban on drinking and oral food intake, with nutritional support provided via a nasogastric tube or enterostomy, as recommended by the authors of the largest series of observations and literature reviews [6; 10], is, in our opinion, disputable. In the above clinical situation, given the normal evacuation of the contrast medium from the stomach into the duodenum and the absence of leakage beyond the stomach in the upright position, we decided not to transfer the patient to tube enteral feeding. Oral fluid intake is a crucial preventive measure for paralytic intestinal obstruction, and our experience has shown that after adequate drainage and daily sanitation of the abscess cavity, oral fluid intake did not have a negative effect on the course of the condition. However, our actions cannot be considered recommendations.

Conclusions

Leackage of the mechanical staple line after longitudinal resection of the stomach is possible. The most effective method for diagnosing insufficiency is abdominal CT with intravenous contrast combined with water-soluble contrast of the stomach. Obviously, the use of a particular treatment technology, or a combination thereof, is determined by the specifics of each clinical case. In our case, a comprehensive approach to treatment, including relaproscopy with sanitation and drainage of acute fluid accumulation, repeated drainage of the cavity under ultrasound guidance, antibiotic therapy with reserve drugs, antisecretory therapy, nutritional support without the installation of a nasogastric tube, enterostomy, and refusal of oral fluid intake, made it possible to eliminate early staple line leackage in a relatively short period of time.

Funding. The study had no external funding.

Conflict of interest. The authors declare no conflict of interest.

Author contributions:

Britvin T.A. – performing the surgery and post-operative care of the patient, concept and writing of the article.

Alaev D.S. – performing the surgery and post-operative care of the patient, editing of the article.

Elagin I.B. – consultation on postoperative management of the patient, editing of the article.

Nadein I.V. – selection and analysis of illustrative material reflecting the results of radiological diagnostic methods.

All authors approved the final version of the article.

Research limitations. The study complies with the standards of the Declaration of Helsinki and has been approved by the independent ethics committee at the Moscow Regional Clinical and Research Institute named after M.F. Vladimirsky, protocol No. 17 dated October 16, 2025. The patient gave her written consent for the publication, communication, and posting on the Internet of information about the nature of the disease, the treatment carried out, and its results for scientific and educational purposes.

About the authors

T. А. Britvin

Moscow Regional Clinical and Research Institute named after M.F. Vladimirsky; «MEDSI Group» Joint Stock Company

Author for correspondence.
Email: t.britvin@gmail.com
ORCID iD: 0000-0001-6160-1342

DSc (Medicine), Head of the Department of Endocrine Surgery

Russian Federation, Moscow; Moscow

D. S. Alaev

«MEDSI Group» Joint Stock Company

Email: t.britvin@gmail.com

PhD (Medicine), Head of the Surgical Department

Russian Federation, Moscow

I. B. Elagin

Rassvet Clinic

Email: t.britvin@gmail.com
ORCID iD: 0000-0002-2645-4129

PhD (Medicine), Surgeon

Russian Federation, Моscow

I. V. Nadein

«MEDSI Group» Joint Stock Company

Email: t.britvin@gmail.com

Radiologist

Russian Federation, Moscow

References

Supplementary files