Nonoperative treatment can be considered for small, contained leaks, particularly in hemodynamically stable patients without peritoneal signs on abdominal exam. The patient should be kept NPO (nothing per oral) with total parenteral nutrition, and broad-spectrum intravenous antibiotic should be administered. The course for nonoperative treatment should be followed with measurement of serial white blood cell (WBC) count, vitals, and physical exam. Patients with increasing WBC, persistent tachycardia, or worsening of abdominal pain should proceed to operative management. In a relatively large study of leaks after gastric bypass, Gonzalez and colleagues reported successful nonoperative treatment in 23 of 26 patients, with an overall morbidity of 62 % and no mortality [17]. Similarly, Casella et al. reported successful nonsurgical treatment of staple-line leaks after laparoscopic sleeve gastrectomy in six patients to include percutaneous drainage along or percutaneous drainage with endoscopic stenting or injection of fibrin glue [18].

The mainstay of surgical treatment includes drainage of all fluid collections and placement of abdominal drains. Additionally, some surgeons make an attempt at closure of the defect; however, these closures tend to break down due to poor tissue integrity at the leak site. Leaks at the jejunojejunostomy or the gastric remnant may be more amenable for primary closure, and revision of the anastomosis is rarely needed [2]. An alternative approach to control the leak site is placement of a T-tube directly into the defect [14]. This technique consists of obtaining a conventional T-tube drain and placing the T part of the drain directly into the defect (Fig. 19.2). The drain is then exteriorized and placed to bag drainage. The T-tube is left in place for 4–6 weeks and is slowly withdrawn over time (1–2 in. per week.). The idea here is to create a track along the drain, hence creating a controlled fistula. Upon withdrawal of thetube, the well-formed fistulous track will collapse and eventually close.

Endoscopic stenting for management of bariatric leaks is a relatively new concept and was initiated from the experience of using endoscopic stenting in management of esophageal anastomotic leaks after esophagectomy [19]. It is important to note that the use of endoscopic esophageal stent for management of leaks is an off-label use of a US Food and Drug Administration (FDA)-approved device for malignant esophageal strictures or fistulas. Table 19.1 demonstrates selected series describing the use of endoscopic stent for treatment of gastric bypass or gastric sleeve leaks (Fig. 19.3) [10–15, 20]. Serra and colleagues reported on the use of coated self-expanding stents for management of leaks after sleeve gastrectomy or duodenal switch in six patients with control of leaks in 83 % of cases [11]. Casella and colleagues reported the use of endoscopic stent for leak at the gastroesophageal junction after sleeve gastrectomy in three patients, with complete healing occurring in all patients [18]. Oshiro and colleagues reported successful management of proximal gastric leak using a covered endoscopic stent in two patients who underwent prior unsuccessful laparoscopic treatment for the leak [13]. In contrast, the largest series of eight cases of endoscopic stent for leak after sleeve gastrectomy was reported by Tan and colleagues [14]. They reported a 50 % success rate for closure of the leak, with four patients requiring premature removal of the stent due to either migration, hematemesis, or obstruction from kinking at the proximal aspect of the stent. One of the major difficulties with usage of stents for control of leaks is their ability to migrate. Eubanks and colleagues described the use of endoscopic stenting in 19 patients, although they described an overall healing rate of 84 %, stents had to be repositioned or replaced in 47 % of patients due to migration. Three patients required reoperation for stent removal. In addition, endoscopic stenting was noted to be less effective for management of chronic fistula in this series. In another report, Fukumoto and colleagues reported a single case of endoscopic stent for leak after sleeve gastrectomy without success that required operative closure of the fistula [15].