Oral Board Case: Bariatric Leak

A patient 3 days post-sleeve gastrectomy has abdominal pain, fever, and tachycardia. What is your leading diagnosis and initial approach?

Expected answer

Staple-line leak until proven otherwise. Tachycardia and fever after bariatric surgery are the earliest signs of a leak, even before overt peritonitis. I would begin immediate resuscitation — IV access, fluids, broad-spectrum antibiotics, labs including CBC, lactate, and blood cultures — while assessing hemodynamic stability. Tachycardia out of proportion to the exam should be treated as a leak, not attributed to pain or anxiety.

What determines whether you go straight to the operating room versus obtaining imaging?

Expected answer

Hemodynamic stability and presence of peritonitis. A patient in septic shock or with diffuse peritonitis needs resuscitation and prompt operative exploration — you should not delay for imaging. If the patient is stable without frank peritonitis, a CT scan with PO and IV contrast is the optimal study to localize the leak and evaluate for a fluid collection or abscess in the left upper quadrant and free air.

This patient has diffuse tenderness and signs of sepsis. How do you proceed?

Expected answer

She has evidence of peritonitis and sepsis, so after aggressive resuscitation she goes to the operating room for exploration rather than to CT. Delaying surgery to chase confirmatory imaging in an unstable/peritonitic patient is a serious error. Resuscitation and operative intervention are the first-line management in this scenario.

Where do sleeve gastrectomy leaks typically occur and why?

Expected answer

75–89% occur in the proximal third of the stomach, near the angle of His. This region is prone to ischemia at the proximal staple line, and a relative stenosis or narrowing distally (e.g., at the incisura) raises intraluminal pressure proximally, promoting leak. Excess tension and staple-line malformation also contribute.

Describe your operative approach for this patient.

Expected answer

Laparoscopic or open exploration with washout of contaminated fluid. Identify the leak, often at the proximal staple line. Options include primary repair with omental buttressing when tissue is healthy, wide drainage of the leak site, and placement of drains. Because inflamed edematous tissue frequently precludes durable primary closure, the mainstays are wide drainage, control of the source, and establishing enteral access (e.g., feeding jejunostomy) or a decompressive tube. Intraoperative endoscopy or methylene blue can help localize the leak.

For a hemodynamically stable patient with a confirmed proximal sleeve leak, what is the preferred initial management?

Expected answer

Endoscopic placement of a self-expanding covered metal stent, which diverts luminal contents away from the leak. Proximal and mid-sleeve leaks are most amenable to stenting. Any associated abscess or fluid collection must be drained percutaneously (CT-guided) in conjunction with stenting, since a stent alone will not control an undrained collection.

How do you manage a stent after placement, and what are common stent complications?

Expected answer

After placement, obtain an upper GI study; if no leak is seen, start clear liquids. Stents stay for at least 2 weeks. The most common complication is migration (5–62% of cases), managed by endoscopic repositioning or placement of a second stent. Any change in clinical status warrants evaluation of stent position with UGI or X-ray.

At the time of stent removal you encounter dense mucosal hyperplasia embedding the stent. What are your options?

Expected answer

For a well-embedded stent due to hyperplastic mucosal growth, options are argon plasma coagulation of the hyperplastic tissue with immediate removal, or the 'stent-in-stent' technique — placing a second stent of the same diameter inside the first to cause pressure necrosis of the hyperplastic mucosa, then removing both stents in 1–2 weeks.

How does leak management differ for a Roux-en-Y gastric bypass patient?

Expected answer

RYGB leaks occur most often at the gastrojejunal anastomosis (70–80%), then the gastric pouch, jejunojejunal anastomosis, and remnant. Diagnosis uses UGI contrast study or CT (CT is more sensitive/specific). Gastrojejunal leaks are amenable to stenting, but jejunojejunal leaks are not — they are hard to access endoscopically and prone to stent migration, so they generally require operative management. The gastric remnant can also be a source and is not endoscopically accessible.