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Endoscopic management of sleeve gastrectomy leaks has been predominantly based on the use of stents. Although they have been very useful in the past, we can consider that nowadays there is a possible overuse, as the different leaks in each individual can’t be treated equally.
When dealing with a patient with a leak after sleeve gastrectomy (SG), we need to take into account whether the infection is localized or lateralized, whether it is early or persistent, and also if there is stenosis involved. A classification is proposed:
Type 1: equivalent to a mild phlegmon on CT or a wound cellulitis
Type 2: abscess, differentiating between close (2a) or lateral/away (2b) from the staple line
Type 3: free leak, peritonitis
Type 4: chronic fistula, differentiating between close (4a) or lateral/away (4b) from the staple line
When dealing with persisting fistulae or abscesses in SG patients, one must assume that at least a functional stenosis may be present. It is also important to take into account that the endoscopic diagnosis of stenosis is specific but has low sensitivity.
Regarding endoscopic treatments of leaks, it is always important to plan the treatment pathway before the first endoscopy. It is recommended to aim for a rapid discharge to decrease both the length of the hospital stay and the perceived degree of suffering by patients. Appropriate resuscitation, antibiotics, and nutrition are the key aspects of the management of early leaks. Endoscopic internal drainage offers interesting advantages compared to percutaneous drainage. When dealing with a patient with peritonitis, surgery is the treatment of choice.
In conclusion, the use of endoscopic therapies is nowadays considered one of the cornerstones in the treatment of leaks after SG due to its advantages in terms of assessment, drainage, dilation, stenting, and feeding of patients.
