Editing Sleeve gastrectomy (section)

=== Early (<30 days) ===

** '''Leaks'''
*** '''Pathophysiology'''
**** About 1.5%
**** Can occur between 1-4        weeks post-op, but most are within the first week
**** Generally proximal third        of staple line
**** More often indolent        infection/abscess rather than frank shock
**** Early leaks thought to be        due to stapler misfires or tissue trauma
**** Later leaks related to        ischaemia and high intra-gastric pressure
*** '''Presentation'''
**** Epigastric/LUQ/shoulder        pain
**** Dysphagia/odynophagia
**** Fever
**** Lethargy
**** Tachycardia, tachypnoea
**** Dyspnoea, pleural        effusion/pneumonia
**** Drain tube discharge
**** Generally not typical        signs of sepsis - HR is best reflection of sepsis
*** '''Risk       factors'''
**** '''Patient        factors'''
***** BMI > 50
***** Revisional surgery
***** OSA/HTN/oxygen         dependency/diabetes/steroids
***** Malnutrition
***** Smoking
**** '''Technical        factors'''
***** Thermal injuries to         gastric tube
***** Stapler         misfiring/mismatched staple height
***** Spiralled staple line
***** Crotch staples
***** Intra-operative problems
***** Narrow bougie <40Fr
***** <1cm to angle of His
***** Aggressive dissection         especially of the posterior attachments of the upper sleeve
*** '''Radiological       assessment'''
**** CT with oral contrast
**** Classify radiologically        according to criteria published by Wendy Brown 2022


Outcomes for grade 1, 2, 3, 4 in successive columns:

* Also classify     early/intermediate/delayed
** Most common within first      month
* For sleeves, almost always     occur at proximal staple line

* '''Management'''
** Principles:
*** Broad-spectrum antibiotic       coverage
*** Identification and repair       of the defect (if possible)
*** Irrigation and control of       contamination
*** Wide drainage (usually       external)
*** Enteral access for feeding
** Medical management:
*** Antibiotics
*** Resuscitation
*** Consider TPN
** Early leaks: In general,      prefer to leave early leaks alone if patient is stable and unless they      have four-quadrant peritonism, to allow the collection to become      organised. Risk of fistula.
** Indications for operation      (laparoscopic washout and drainage if possible; generally avoid      definitive management; consider placement of enteral feeding access):
*** Unstable patient
*** Diffuse peritonism
*** Free gas
*** Free contrast
** Abscesses can be treated      percutaneously
*** Beware of possibility of       converting it into an enterocutaneous fistula
** Novel therapies:
*** Fully covered stents
**** One study showed healing        rate 90% in six weeks but migration occurs in almost half
**** Not used for this        indication in modern times
*** Endoscopic vacuum therapy
**** Need frequent RTT to        change it
*** Internal/external drain
*** Clips
*** Could even consider       converting to RYGB

* Haemorrhage
* Sleeve stricture
* Wound infection