Staple line leaks after bariatric surgery are uncommon, but one of the main short-term risks we look for after a sleeve gastrectomy, gastric bypass, or duodenal switch. Read this article to understand more about the staples we use in surgery, what a staple line leak is, and how we treat them.
To understand what a staple line leak is, first you should know what the staples look like! This is a quick video that shows the staplers that are used in surgery* and a staple line reinforcing agent. Staple line leaks are a risk for about the first four weeks after gastric bypass, duodenal switch, and sleeve gastrectomy.
We use Echelon staplers (Ethicon Endo-surgery, Cincinnati, Ohio) and a staple line reinforcing agent product called Seamguard (W.L Gore and Associates, Newark, DE) in all our staple lines. The Seamguard is stapled into the staple line, sort of like the cloth backing of a zipper, to give extra protection from leaks and bleeding. Seamguard is a “bioabsorbable” product, so it simply goes away after 6-8 weeks when it is no longer needed.
These staplers fire 6 rows of tiny little titanium staples and divides down the middle, leaving 3 rows of staples on each side of the two staple lines. Three rows of staples provides for a stronger staple line and reduces the chance of leaks and bleeding.
A staple line leak usually happens in the 3rd or 4th week after surgery, when a few staples pop out (usually for unknown reasons). This can allow gastric contents to leak out from the sleeve and into the abdominal cavity. Most of the time when this happens it results in a small fluid collection, or “abscess”, next to the sleeve. The risk of a staple line leak after bariatric surgery is low, in most studies around 1-2%.
- What are the signs of a leak?
- The patient is usually 2-4 weeks out from surgery
- Fevers (over 100.4)
- Left upper quadrant belly pain
- Increasing pain each day (as opposed to normally decreasing pain)
- Rarely ever happens after 6th week
- How are leaks diagnosed?
- CT scan
A CT scan is often the first test done when staple line leaks after bariatric surgery are suspected. In the image above next to the red circle you can see a bright white line, which is the staple line. Within the red circle you can see some air bubles (which appear black). These air bubles are outside of the staple line, showing that some air that the patient swallowed is now outside of the sleeve.
CT scans are good not only for finding staple line leaks after bariatric surgery, but also for treating them. The radiologists can insert a small drain tube (called a percutaneous drain) into the area where the leak is, to allow any infection to drain out. This drain is then left in until the leak heals.
- Upper GI
Upper GI’s are xrays that are done under live fluoroscopy while the patient swallows some contrast dye. The contrast dye shows up as white on an xray. In the xray above the sleeve is the long column of white dye that heads up towards the upper left corner of the xray. You can see a small amount of dye within the red circle, that is outside of the sleeve. This indicates a leak.
An endoscopy is when we sedate a patient and insert a scope into the mouth, down through the esophagus, and into the sleeve. They are useful mainly for treating leaks, but can at times be used to diagnose them as well. The image above shows the view through the endoscope of a sleeve. Within the red circle you can see a small pinhole leak. In this case multiple treatment options could be used, including clips or endoscopic sutures to close the leak, or more commonly inserting an esophageal stent to cover the leak.
Stents are left in place for around 8 weeks. This allows time for the leak to heal while the stent provides coverage to prevent further leakage. During this time usually a drain has already been put in already, and the patient is given IV antibiotics and IV nutrition. A small percentage of patients (10-20%) who have leaks may require surgery to correct those that will not heal with stenting or other endoscopic treatments.
In summary, staple line leaks after bariatric surgery are uncommon but a known possibility. They are not life threatening as long as they are promptly treated, and they usually can be resolved without surgery. At Metabolic Weight Loss Centers with Dr. Curry, Pitt, and Udelhofen, we take every step we can to reduce your risk of a complication after surgery, but the patient must participate also. In order to reduce your risk of a leak, be sure to follow your dietitian’s instructions on your post op diet!
*This is not the exact stapler or reinforcement agent that we use but the concept is the same