Leaks after sleeve gastrectomy: is it still an issue?-single-center experience and systematic literature review

Background: Sleeve gastrectomy (SG) has grown into a well-standardized standalone procedure, currently representing the utmost prevalent operation globally for the treatment of morbid obesity. Although this operation is considered relatively simple, the most feared complication still persists to be a staple line disruption with consequent gastric leak. We sought to identify whether an increased surgeon's experience during different time periods within Sapienza University of Rome played a role in the development of gastric leaks following SG, also providing a systematic literature review. Methods: Two cohorts of patients undergoing SG at Sapienza University Hospital were matched: those operated prior to (group A) or after (group B) 2011. Additionally, an electronic literature search of articles published on leaks after SG was completed. Retrieved articles were subdivided into three 5-year periods (2006-2010, 2011-2015, and 2016-2020). Results: The two cohorts of patients, group A (n=361) and group B (n=514) were analyzed. Median age was 42 [interquartile range (IQR), 18-67] years in group A and 42 (IQR, 19-70) years in group B. Postoperative body mass index (BMI) was 28 (IQR, 17-52) kg/m2 in group A and 27 (IQR, 19-41) kg/m2 in group B (P<0.001). Bioabsorbable reinforcement was used in 158 (43.8%) patients in group A and 338 (65.7%) in group B (P=0.01). Twelve staple line leaks occurred in group A (3.3%) and 4 leaks in group B (0.8%) (P=0.008). Six (50%) out of 12 leaks in group A, vs. 1 (25%) leak in group B had no reinforcement. Reinforcement showed a negative correlation with leak occurrence (P=0.03). A total of 66 studies were included, encompassing 89,407 patients and 923 leaks (overall incidence: 1.03%). The mean leak rate was 3.07% in the first 5-year period, 1.41% in the second, and 1.37% in the last 5-year period. The number of SG procedures performed inversely correlated with the percentage of leaks (P<0.05). Conclusions: Percentage of leaks significantly decreased over time in our cohorts which reflected literature data. The increasing expertise in parallel with the growing number of SGs performed is associated with a substantial decrease in overall leak rates and might be correlated with improved weight outcomes.