A 4-tier Protocolized Radiological Classification System for Leaks Following Sleeve Gastrectomy

Abstract

Objectives: To develop and validate a classification of sleeve gastrectomy leaks able to reliably predict outcomes, from protocolized computed tomography (CT) findings and readily available variables. Summary of Background Data: Leaks post sleeve gastrectomy remain morbid and resource-consuming. Incidence, treatments, and outcomes are variable, representing heterogeneity of the problem. A predictive tool available at presentation would aid management and predict outcomes. Methods: From a prospective database (2009-2018) we reviewed patients with staple line leaks. A Delphi process was undertaken on candidate variables (80-20). Correlations were performed to stratify 4 groupings based on outcomes (salvage resection, length of stay, and complications) and predictor variables. Training and validation cohorts were established by block randomization. Results: A 4-tiered classification was developed based on CT appearance and duration postsurgery. Interobserver agreement was high (k ¼ 0.85, P < 0.001). There were 59 patients, (training: 30, validation: 29). Age 42.5 AE 10.8 versus 38.9 AE 10.0 years (P ¼ 0.187); female 65.5% versus 80.0% (P ¼ 0.211), weight 127.4 AE 31.3 versus 141.0 AE 47.9 kg, (P ¼ 0.203). In the training group, there was a trend toward longer hospital stays as grading increased (I ¼ 10.5 d; II ¼ 24 d; III ¼ 66.5 d; IV ¼ 72 d; P ¼ 0.005). Risk of salvage resection increased (risk ratio grade 4 ¼ 9; P ¼ 0.043) as did complication severity (P ¼ 0.027).Findings were reproduced in the validation group: risk of salvage resection (P ¼ 0.007), hospital stay (P ¼ 0.001), complications (P ¼ 0.016). Conclusion:We have developed and validated a classification system, based on protocolized CT imaging that predicts a step-wise increased risk of salvage resection, complication severity, and increased hospital stay. The system should aid patient management and facilitate comparisons of outcomes and efficacy of interventions.

Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication

“…It would be ideal to compare series using an objective classification system. The Johari grading system is highly sensitive in identifying leaks and that data has shown to closely correlate with outcomes [ 23 ]. This grading system provides a valuable tool for comparing the true incidence of sleeve leaks and their resolution and overcomes the confounder of variable definitions and data collections used across different centres.…”

Diagnosis and Management of Postoperative Complications After Sleeve Gastrectomy

“…Recently, Johari et al suggested a radiologic classification system for sleeve leaks, which divided leaks into four groups based on the CT findings, demonstrating a step-wise increased risk of complication severity and salvage surgery ( Fig. 2 ) [ 29 ].…”

“… Figure reprinted from Johari et al Ann Surg 2022;275(2):e401-e409, with permission from the publisher, Wolters Kluwer Health [ 29 ]. …”

Mechanism of Staple Line Leak After Sleeve Gastrectomy via Isobaric Pressurisation Concentrating Stress Forces at the Proximal Staple Line

“…Staple line leak is a morbid complication after sleeve gastrectomy and frequently results in a protracted recovery, significant morbidity, and occasionally mortality [ 1 , 2 ]. Leaks almost always occur in the proximal staple line within 1–2 cm of the gastro-oesophageal junction [ 3 , 4 ]; however, the precise pathophysiology is not well delineated [ 5 ]. An understanding of the precipitating factors driving leak could provide technical insights into sleeve construction that could reduce the incidence of chronic leak and aid decision making during their management.…”