Prevention

Leak after MBS is considered one of the most dreaded complications that can be potentially fatal if there is delay in diagnosis and management. Hence, prevention and early detection are of significant importance. Prevention of leak after MBS can start with proper patient selection and the attention to proper surgical technique and utilising measure for early detection such as the use of routine intraoperative endoscopy to detect leaks early. For example, to highlight the importance of patient selection, Alizadeh et al. conducted a study in 2015 including 135 000 patients after either SG or RYGB. The overall leak rate was 0.7%, and factors associated with increased risk for leak were oxygen dependency, hypoalbuminemia, OSA, hypertension and type 2 diabetes. These factors therefore need to be pre‐operatively optimised to minimise the risk of leak. Early detection of leaks after RYGB was outlined in a study by Al Hadad et al. in 2015 including 342 patients between the years of 2009–2014. In this study, positive air leaks were seen in six cases (1.8%), and five out of six went on not to have a leak after RYGB; the positive predictive value of IOE with leak test was 75%, and the negative predictive value was 99.5%. The sensitivity of intraoperative endoscopy as a leak test enables surgeons to have the ability to make adjustments to operative strategy and minimise the risk of post‐operative leak. Other leak tests include the use of methylene blue.

Management of Leaks After MBS

Outcomes of leaks after MBS can be catastrophic if the patients were not made aware of their possibility and/or there was a delay in detection and early management. It is of utmost importance to discuss the possibility of complications especially leaks with patients and their families, and have a clear plan to manage them. Additionally, leaks are not only related to the learning curve of the practicing surgeon as surgeons will manage more complex patients as they become more experienced. In a study, Dallal et al. in 2014 demonstrated that the probability of a medical malpractice lawsuit correlated positively to the number of procedures performed by the bariatric surgeon and the number of years the surgeon has been in practice.

Early detection of leak after MBS is key to prevent major morbidity, and possible mortality failure to do is coined as ‘failure to rescue’. In a study conducted by Dimick et al. at the University of Michigan, the complications and mortality were compared for >300 hospitals. Dimick et al. showed that despite hospitals having a similar rate of major complications and all complications, the mortality rate was not similar with some hospitals failing to rescue their patients. In order to facilitate early detection, the education of emergency department physicians as well as emergency department and surgical residents will help improve the quality of patient care.

The basic strategy for management of leaks after MBS is similar to the management of any upper gastrointestinal leak, and this strategy is to control sepsis, drain the leak, provide enteral feeding rather than parenteral feeding and make sure patients do not have distal obstruction such as stenosis in RYGB leaks. In addition, drainage and nutrition are the main tenants for the treatment of leaks after MBS; if possible, nutrition enterally via a G or J tube is preferred to parenteral nutrition.

Education of the Multi‐Disciplinary Team

We have developed 10 clinical pearls that can guide the evaluation of post‐operative bariatric patients by emergency department physicians:

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