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In stable patients, less-invasive non-surgical management should be attempted. This includes a wide range of endoscopic interventions, from endoscopic stenting and direct fistula closure, to internal drainage and radiologic interventions. Adequate drainage has been the most important treatment for early leaks, and abscesses can be drained percutaneously or endoscopically. The gastric wall defect needs to be repaired either by diverting the fistula or by direct closure. Endoscopic intervention depends on the size and characteristics of the defect [ 22]. It is important to complete this stage as your stomach pouch will be very small and tight at first. Puree foods are smooth and can pass through your stomach easily. You will need to use a blender, liquidiser or food processor to puree your food to the correct consistency. Aim for a smooth consistency like ‘yoghurt’. Borbély Y, Osterwalder A, Kröll D, Nett P, Inglin R. Diarrhea after bariatric procedures: Diagnosis and therapy. World J Gastroenterol. 2017;23(26):4689. doi:10.3748/wjg.v23.i26.4689 Al-Sanea O, Al-Garzaie A, Dernaika M, Haddad J. Rare complication post sleeve gastrectomy: Acute irreducible paraesophageal hernia. Int J Surg Case Rep. 2015;8C:88-91. doi:10.1016/j.ijscr.2015.01.040 After sleeve gastrectomy, your diet begins with sugar-free, noncarbonated liquids for the first seven days, then progresses to pureed foods for three weeks, and finally to regular foods approximately four weeks after your surgery. You will be required to take a multivitamin twice a day, a calcium supplement once a day, and a vitamin B-12 injection once a month for life.

Try to have 1.5-2 litres of fluids each day. Aim for at least 1litre (2 pints) of milk based fluids (see list of protein rich fluids above) and always prioritise protein rich fluids over others such as tea, coffee etc. Begin with sipping your drinks little and often and gradually increase the quantity until the sensation of feeling full occurs. It is important to stop as soon as you feel full. If you drink too much, your stomach may overfill and cause pain, nausea and vomiting. Stage 2 – only puree foods for 2 weeks Breakfast: Weetabix, Oatibix or Ready Brek with plenty of skimmed milk OR high protein yogurt pot or pouch Askari A, Arhi C, Mamidanna R. Quality of life following bariatric and metabolic surgery. In: Patient Reported Outcomes and Quality of Life in Surgery. Cham: Springer International Publishing; 2023:85-96. doi:10.1007/978-3-031-27597-5_7

Introduction

Wang Y, et al. Mechanisms ofweight loss after sleeve gastrectomy and adjustable gastric banding: Far more than just restriction. Obesity. 2019; doi:10.1002/oby.22623. The Cheyne Child Development Service - School age Autism (ASD) Assessment Pathway Parent Information

Abdominal CT after contrast swallow in a patient with a sleeve leak. Disruption of the staple lines (a), extralumination of the contrast medium to the left subphrenic area (b, c), reactive pleural effusion (d). As with any major surgery, sleeve gastrectomy poses potential health risks, both in the short term and long term. Tissue sealants have also been used to close the fistulas. Fibrin glue functions in two ways: mechanical occlusion of the defect and promotion of fibroblast proliferation. The glue can be delivered endoscopically or radiologically, and multiple sessions with intervals of several days are usually required to occlude the fistula completely. Assalia et al. [ 38] reported that percutaneous application of fibrin glue with fluoroscopic guidance under endoscopic visualization achieved successful fistula closure in 23 of 24 patients with sleeve leak patients with 2.2 sessions on average (range, 1–6). This suggests that plugging leaky sleeves with tissue sealant is a simple, tolerable, and effective method to treat sleeve leaks with fewer complications. The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss: A two-centre retrospective cohort study. Int J Surg. 2016;30:13-18. doi:10.1016/j.ijsu.2016.03.060Palermo M, Acquafresca PA, Rogula T, Duza GE, Serra E. Late surgical complications after gastric by-pass: a literature review. Arq Bras Cir Dig. 2015;28(2):139-143. doi:10.1590/S0102-67202015000200014 When surgical exploration was performed on leak patients in the earlier period, the goal of surgical management was not a definitive repair of the leak but to wash out and remove the necrotic debris and to place proper drains. A simple primary repair might be attempted in acute leaks within three days after surgery when promptly diagnosed [ 30]. Nonetheless, it is usually less successful, with a high incidence of recurrence owing to extensive inflammation in the surrounding tissue. In the latter phase, when non-surgical management fails after three to six months, surgery can be used as a step-up or salvage therapy. This includes conversion to RYGB and fistulojejunostomy. Levy JL, Levine MS, Rubesin SE, Williams NN, Dumon KR. Stenosis of gastric sleeve after laparoscopic sleeve gastrectomy: clinical, radiographic and endoscopic findings. Br J Radiol. 2018;91(1089):20170702. doi:10.1259/bjr.20170702

Bariatric-specific endoscopic stents. (A) GastroSeal™ stent (M.I.TECH, Pyeongtaek, Korea), (B) MEGA™ stent (TaewoongMedical Co., Ltd. Gimpo, Korea), (C) BETA™ stent (TaewoongMedical Co., Ltd. Gimpo, Korea). Do not drink with meals. Drink 20 minutes before meals and then wait at least 20 minutes after a meal before you drink some fluids Bruze G, Holmin TE, Peltonen M, et al. Associations of bariatric surgery with changes in interpersonal relationship status: Results from 2 Swedish cohort studies. JAMA Surg. 2018;153(7):654–661. doi:10.1001/jamasurg.2018.0215Alhuzaim WM, Alajlan RM, Alshehri RA, et al. Post-gastric sleeve surgery chronic symptoms from a sample of patients in Saudi community. Cureus. 2023;15(7). doi: 10.7759/cureus.42000 Lim RB. Bariatric procedures for the management of severe obesity: Descriptions. https://www.uptodate.com/contents/search. Accessed June 8, 2020. Another method involves the application of fibrin sealants. A recent meta-analysis including 2,136 SG patients from nine randomized controlled trials showed that there was a tendency toward less bleeding with fibrin sealant application compared to no reinforcement [ 8]. However, the hemostatic role of sealants was not evident in that meta-analysis of trials with larger samples [ 17]. It is still not clear whether applying fibrin sealant alone could reduce the incidence of postoperative bleeding. Half your meal portion should be from a protein rich food. Try adding 2tsp of protein or skimmed milk powder to your puree foods Choose foods that are high in protein to help you to meet your protein requirements (at least 70g protein each day). Aiming for at least 500ml (1 pint) of protein rich fluids daily will help you achieve this. How much and when?