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Leaks after sleeve gastrectomy – A narrative review

Background: Laparoscopic sleeve gastrectomy has become a standalone procedure for the treatment of severe obesity with excellent short- and mid-term outcome. Staple-line leak is one of the most dreaded complications of this procedure. Following a standardized sequence of critical steps can help decrease the incidence of leaks. In this review, we examine the etiopathogenesis of leaks after laparoscopic sleeve gastrectomy and important implicated technical considerations. Materials and Methods: A comprehensive literature search of various databases was performed with relevant keywords. The published scientific literature was critically appraised. Results: Patient-, surgery-, and surgeon-related risk factors should be recognized and modifiable risk factors should be addressed. There are anatomical, physiological, and technical considerations that contribute to the pathogenesis of leaks, based on which a multitude of precautions need to be taken to prevent staple-line leak. Conclusion: The correct bougie size, distance from the pylorus, stapler size, orientation of staple line, and distance from angle of His and an intraoperative leak test are some of the crucial aspects for a successful outcome after sleeve gastrectomy. Staple size less than that of 1.5 mm should not be used on the stomach, stapling should be initiated at least 5 cm from pylorus and calibrated on a bougie that should not be <32 Fr size. Reinforcing the staple line reduces the incidence of hemorrhage, and current evidence indicates the incidence of leak. Performing a leak test, though offers less sensitivity to predict a leak, does help in detecting the immediate mechanical failure of staple line.