Staple-Line Leak After Gastric Sleeve: Signs, Timing and Treatment

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Staple-Line Leak After Gastric Sleeve: Signs, Timing and Treatment

A staple-line leak is a small opening in the row of staples that seals the stomach after a sleeve gastrectomy. Stomach fluid escapes into the abdomen and can cause a serious infection. Leaks are uncommon. The usual signs are a fast heart rate, fever and worsening pain, often after you have gone home. A leak needs hospital care, not a wait for an appointment.

What a staple-line leak is

In a sleeve gastrectomy the surgeon removes most of the stomach and closes the remaining tube with a long line of surgical staples. A leak happens when part of that line does not heal and fluid seeps through. A 2022 review by Park in the Journal of Metabolic and Bariatric Surgery reports that up to 90% of sleeve leaks occur at the upper end of the staple line, near where the stomach meets the esophagus (the swallowing tube). An earlier analysis by Aurora and colleagues found 89% in the upper third of the stomach.

The same review explains why the sleeve behaves differently from a gastric bypass. The long staple line and the high pressure inside the narrow tube make a sleeve more prone to leaking. A narrowing lower down in the sleeve can raise that pressure further.

How often it happens

Published figures vary with the era and the type of study. A systematic analysis of 29 publications covering 4,888 sleeve patients (Aurora and colleagues, Surgical Endoscopy, 2012) put the risk of a leak at 2.4%. The Park review gives a reported range of 1% to 6%, closer to 1% in recent series as risk factors have become better recognized.

Registry data are lower again. An analysis of the national MBSAQIP database from 2015 to 2017 (Jung and colleagues, Surgical Endoscopy, 2022), drawn from 363,042 bypass and sleeve patients, compared matched groups with and without a leak test during surgery. Their 30-day leak rates were 0.3% to 0.4% after a first-time sleeve and 0.7% to 1.1% after a revision sleeve. Our gastric sleeve risks page sets this beside the other complications.

When leaks show up

Many people assume that if they left the hospital feeling well, the danger has passed. The evidence says otherwise. In the Aurora analysis most leaks were diagnosed after discharge, and the authors stress close follow-up during the first 30 days. A study of 80 leak patients at a center in Qatar (Al Zoubi and colleagues, Obesity Surgery, 2021) found the same pattern: 75 of the 80 were diagnosed after discharge, on average 18 days after surgery.

That study also shows why you should say plainly that you had a sleeve. Only 29.3% of those patients were correctly diagnosed at their first emergency room visit. Others were first thought to have gastritis or pneumonia.

Signs of a leak

Al Zoubi and colleagues describe a fast heart rate (tachycardia), fever and abdominal pain as the most common signs of a leak after a sleeve, though not the only ones. In their patients abdominal pain occurred in 90%, a fast heart rate in 71.3% and fever in 61.3%. The pain can spread to the left shoulder or shoulder blade. Other signs to take seriously include:

Pain that is getting worse each day instead of better
Pain in the shoulder or back
Shortness of breath or fast breathing
Chills, sweats or a general feeling that something is wrong
Nausea or vomiting that will not settle

The Park review notes that the picture varies widely, and that some people have no symptoms at all. Blood tests do not settle the question either. Al Zoubi and colleagues report that some authors found them rarely helpful, while most of their own patients had raised infection and inflammation markers. Results are read together with how you look and feel.

How a leak is found

The main test is a CT scan, often with contrast you drink. Al Zoubi and colleagues cite a multicenter study in which CT had a sensitivity of 83% to 93%. Sensitivity means how often a test finds a leak that is there. A CT that includes the chest can also show other causes of a fast heart rate or shortness of breath, such as pneumonia or a blood clot in the lung.

The swallow X-ray, called an upper GI contrast study, has mixed results in the literature. The Park review reports a sensitivity of 0% to 25%. In the Qatar study it showed contrast escaping in 77.5% of patients, close to the 75% seen on CT.

No scan is perfect. The Park review warns that imaging can be falsely normal, and that people who are unstable should go to surgery for direct exploration whatever the CT shows.

How a leak is treated

Treatment depends on how sick you are, where the leak is and how long after surgery it appears. The Park review lists the mainstays as medical resuscitation, draining infected fluid and repairing the defect, with early broad-spectrum antibiotics and high-dose acid-reducing medicine.

Drainage. Infected fluid is drained, either with a tube placed through the skin, through an endoscope or during an operation.
Nutrition. Some treatments require feeding through a tube or a vein for a time. Others allow earlier eating by mouth.
Endoscopic treatment. A covered stent, a flexible tube placed through the mouth, can bridge the leak while it heals. Stents usually stay in for four to six weeks. The Park review reports closure rates of up to 100% with stents designed for bariatric patients, at the cost of more stent complications. Stents can also move, in up to 30% of cases depending on the type. Other endoscopic options include internal drainage, clips and vacuum therapy.
Surgery. People who are unstable usually need an operation right away. If other treatment has failed after three to six months, surgery such as conversion to a gastric bypass may be used. See gastric sleeve revision options, and ask the office which of these procedures are available through the practice.

When to call

Go to an emergency room or call 911 if

You have a fever together with a fast heart rate or shortness of breath in the first weeks after surgery
You have severe or steadily worsening abdominal, chest or left shoulder pain
You cannot keep liquids down
You feel faint or confused, or you are vomiting blood

Tell the staff you had a sleeve gastrectomy, the date, and your surgeon's name. The complete list is on our emergency warning signs page.

Call the office the same day if

Your temperature is mildly raised but you otherwise feel well
An incision is red, swollen or draining
Pain is not improving, or you are struggling to reach your fluid goal

If you cannot reach anyone and you are getting worse, go to the nearest emergency room.

Frequently asked questions

Can a gastric sleeve leak years after surgery?

A new leak years later is not the usual pattern. The studies cited here describe leaks as a problem of the first days and weeks, with most diagnosed after discharge. A leak that began early can, however, last for months as a chronic opening called a fistula. New pain or fever years after a sleeve has other possible causes and still deserves prompt evaluation.

Does a normal leak test in the operating room mean I cannot leak?

No. In the MBSAQIP analysis by Jung and colleagues, 30-day leak rates after a first-time sleeve were similar with or without a leak test during the operation (0.4% and 0.3%). A test at the time of surgery checks the staple line at that moment. Many leaks appear later, during healing. Ask your surgeon whether a leak test or an X-ray after surgery is planned for you.

What raises the risk of a sleeve leak?

The Park review names technical factors such as a narrow sleeve and a narrowing at the bend of the stomach, and health factors such as diabetes, low albumin (a blood protein) and long-term steroid use. In the Aurora analysis the leak rate was 2.9% in people with a BMI above 50 and 2.2% below that. Revision operations also had higher rates than first-time sleeves in the MBSAQIP data.

Will a leak mean my sleeve has to be converted to another operation?

Often not. The Park review describes drainage, antibiotics and less invasive endoscopic treatment as the approach to try first in stable patients. Surgery is used for people who are unstable or whose leak does not heal. When other treatment has failed after several months, the sleeve may be converted to a gastric bypass. Ask your surgeon which applies to you.

Talk with Dr. Davtyan in Rancho Cucamonga

Dr. David G. Davtyan, MD, FACS, FICS, FASMBS, is a bariatric surgeon at Davtyan Medical Weight Loss & Wellness, 8330 Red Oak Street, Suite 201, Rancho Cucamonga, CA 91730. If you are planning surgery, ask at your visit how leaks are watched for and what to do if symptoms start after hours. Call 909-355-2525 or toll free 877-9-BE-SLIM (877-923-7546), or use our contact page. The first consultation is complimentary, and Hablamos Español. More topics are in our Rancho Cucamonga gastric sleeve guide.

Staple-Line Leak After Gastric Sleeve: Signs, Timing and Treatment

Staple-Line Leak After Gastric Sleeve: Signs, Timing and Treatment

What a staple-line leak is

How often it happens

When leaks show up

Signs of a leak

How a leak is found

How a leak is treated

When to call

Go to an emergency room or call 911 if

Call the office the same day if

Frequently asked questions

Can a gastric sleeve leak years after surgery?

Does a normal leak test in the operating room mean I cannot leak?

What raises the risk of a sleeve leak?

Will a leak mean my sleeve has to be converted to another operation?

Talk with Dr. Davtyan in Rancho Cucamonga

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More in the Gastric Sleeve in Rancho Cucamonga guide

Understanding the sleeve

Weighing your options

Getting care in Rancho Cucamonga

Adult BMI Calculator

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Rancho Cucamonga

South Coast Lap-Band

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