Post written by Jessica X. Yu, MD, MS, and Allison R. Schulman, MD, MPH, from the Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.

We described the case of a 48-year-old woman with a history of a sleeve gastrectomy complicated by a refractory staple line leak. The patient presented 2 weeks after surgery and underwent transgastric drainage of the perigastric abscess with plastic pigtail placement, as well as pneumatic dilation of a concurrent sleeve stenosis at the incisura. Despite this, the leak persisted through her abdominal incision leading to progressive skin breakdown. A fully covered self-expanding metal stent (FCSEMS) was placed. She continued to be unable to tolerate oral intake. Repeat endoscopy 12 weeks following surgery demonstrated a chronic fibrous septum between the necrotic cavity and stomach lumen. We performed a septotomy using an insulated cutting knife, which allowed for the division of the entire septal wall in a single session. Following septotomy, the patient was able to advance her diet. Subsequent imaging demonstrated the resolution of her fluid collection.

Our video demonstrates various strategies and techniques for the management of a gastric sleeve leak. We used a step-wise approach starting with transgastric drainage and concurrent pneumatic dilation followed by endoscopic diversion with FCSEMS placement during the acute phase, and ultimately septotomy once the leak had become chronic. The use of an insulated cutting knife allowed us to perform the septotomy safely in a single session. Pneumatic dilation and removal of foreign body material are important adjunctive interventions to promote leak healing.

There were several important aspects of this case. The management of sleeve leaks is based on the timing of presentation and the chronicity of the leak. Septotomy can be successfully used to manage late or chronic leaks (>6-12 weeks) and can be performed with various devices (insulated cutting knife, needle knife, and argon plasma coagulation).  Gastric sleeve stenosis may promote the development of a gastric sleeve leak, and therefore dilation is an important strategy to promote healing.  Additionally, the removal of foreign material such as staples or sutures at the leak site is also important.

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