Leak After Sleeve Gastrectomy With Positive Intraoperative Indocyanine Green Test: Avoidable Scenario?
Conditions: Obesity, Morbid, Diabete Type 2, Cardiac Disease, Vascular Diseases
Sponsor: University of Foggia

LEAK 
AFTER 
SLEEVE 
GASTRECTOMY 
WITH 
POSITIVE INDOCYANINE GREEN TEST: AVOIDABLE 
SCENARIO? 
 
RUNNING HEADS: Indocyanine green test for evaluation of perfusion of staple 
line of the stomach during laparoscopic sleeve gastrectomy 
 
AUTHORS: 
GIOVANNA 
PAVONE1, 
NICOLA 
TARTAGLIA1, 
MARIO 
PACILLI1, 
FRANCESCA 
MADDALENA1, FABIO PETRUZZELLI1,GENNARO MARTINES2, MICHELE DE FAZIO2, , 
ANTONIO AMBROSI1,. 
 
 
AUTHORS: 
GIOVANNA PAVONE1 MD, giovanna.pavone@unifg.it, DEPARTMENT OF MEDICAL AND 
SURGICAL SCIENCES, UNIVERSITY OF FOGGIA, VIALE PINTO, 71122, FOGGIA, ITALY. 
NICOLA TARTAGLIA1 Prof. FACS,nicola.tartaglia@unifg.it, DEPARTMENT OF MEDICAL 
AND SURGICAL SCIENCES, UNIVERSITY OF FOGGIA, VIALE PINTO, 71122, FOGGIA, 
ITALY. 
MARIO PACILLI1 MD,mario.pacilli@unifg.it, DEPARTMENT OF MEDICAL AND SURGICAL 
SCIENCES, UNIVERSITY OF FOGGIA, VIALE PINTO, 71122, FOGGIA, ITALY. 
FRANCESCA 
MADDALENA1 
MD,franc.maddalena@gmail.com, 
DEPARTMENT 
OF 
MEDICAL AND SURGICAL SCIENCES, UNIVERSITY OF FOGGIA, VIALE PINTO, 71122, 
FOGGIA, ITALY. 
FABIO PETRUZZELLI1 MD,fabpetruzzelli33@gmail.com, DEPARTMENT OF MEDICAL AND 
SURGICAL SCIENCES, UNIVERSITY OF FOGGIA, VIALE PINTO, 71122, FOGGIA, ITALY. 
GENNARO MARTINES2 Prof.,gerrymartines@virgilio.it, DEPARTMENT OF GENERAL 
SURGERY AND LIVER TRANSPLANTATION, UNIVERSITY OF BARI, 70124 BARI, ITALY. 
MICHELE DE FAZIO2 Prof.,michele.defazio@uniba.it, DEPARTMENT OF GENERAL 
SURGERY AND LIVER TRANSPLANTATION, UNIVERSITY OF BARI, 70124 BARI, ITALY. 
ANTONIO AMBROSI1 Prof.,antonio.ambrosi@unifg.ti, DEPARTMENT OF MEDICAL AND 
SURGICAL SCIENCES, UNIVERSITY OF FOGGIA, VIALE PINTO, 71122, FOGGIA, ITALY. 
 
AFFILIATIONS: 
1: DEPARTMENT OF MEDICAL AND SURGICAL SCIENCES, UNIVERSITY OF FOGGIA, 
VIALE PINTO, 71122, FOGGIA, ITALY. 
2:DEPARTMENT OF GENERAL SURGERY AND LIVER TRANSPLANTATION “M. 
RUBINO”, UNIVERSITY OF BARI, 70124 BARI, ITALY. 
 

CORRESPONDING AUTHOR: 
NICOLA TARTAGLIA, nicola.tartaglia@unifg.it, Viale Pinto 1, 71122 Foggia, Italy 
tel./fax +39 0881.733808 
 
 
Date Document: 30/03/2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ABSTRACT 
 
BACKGROUND: The staple line gastric leak (GL) is estimated to be the most serious 
complication of the sleeve gastrectomy. The use of indocyanine green (ICG) has been 
introduced in minimally invasive surgery to showthe vascularization of the stomach in 
real time and its application to the gastroesophageal junction (GE) during Laparoscopic 
Sleeve Gastrectomy (LSG) seems very promising. 
CASE PRESENTATION: We present the case of a 40-year-old female underwent 
laparoscopic sleeve gastrectomy. Intraoperative indocyanine green test showed a small 
dark area in the proximal third of the staple line reinforced with fibrin glue. Two weeks 
later the patient presented to the emergency room (ED) with abdominal pain, fever, 
vomiting, intolerance to oral intake and the evidence of a leak on the abdomen 
Computer Tomography (CT). 
CONCLUSIONS: This case report shows that intraoperative ICG test can be helpful in 
determining which patients are at greater risk of the leak and, more importantly, the 
cause of the leak but further tests are needed to determine if the ICG predicts leak due 
to ischemia. 
 
 
 
 
 
 
 
 
 
 
 
 
Key words: laparoscopic sleeve gastrectomy, Indocyanine green test, gastric fistula. 

INTRODUCTION 
 
Obesity is a major current public health problem of global significance.Obesity is 
associated with a myriad of serious health conditions, including hypertension, type II 
diabetes mellitus, sleep disorders, dementia, cardio-vascular diseases, and various 
malignancies, and is associated with increased morbidity and mortality [1]. 
Laparoscopic sleeve gastrectomy (LSG) has become in the last decades the most 
frequently performed bariatric procedure worldwide since it is a less demanding 
procedure compared to Roux-en-Y gastric bypass (BRGY), with a shorter operative time 
and absence of anastomosis. [2] 
The staple line gastric leak (GL) is estimated to be the most serious complication of this 
procedure, due to a difficult healing process when using a non-standardized endoscopic 
approach, with a currently reported rate of 0.4 to 2.7%. [3] 
Post LSG leaks can be misdiagnosed, resulting in delayed management and catastrophic 
consequences [4,5]. The clinical presentation, signs, and symptoms are highly variable, 
ranging from asymptomatic to septic shock [6].  
Fistulas are complex and have multifactorial origins. Situations that cause difficulty in 
gastric emptying, with a consequent increase in intraluminal pressure, may lead to a 
rupture of the stapling line in the region of the esophagogastric junction, at the His 
angle, causing a gastric fistula [7]. Stapling failures, gastric twist, tissue damage, and distal 
strictures are some of the conditions that pose an additional risk for the development of 
fistulas after SG [8, 9].  
The use of indocyanine green (ICG) has been introduced in minimally invasive 
surgery[10-12]. 
Indocyanine Green (ICG) is a liquid that can be injected into the human bloodstream 
without adverse effects. [13] The ICG fluoresces when excited with light of wavelength 
in the near infrared (NIR) spectrum (approximately 820 nm) [14] [15, 16]. Special 
telescopes detect the fluorescence that is transmitted to a standard monitor that allows 
the identification of the anatomical structures in which the dye is present (eg biliary tract, 
vessels, lymph nodes, etc.). It is a low cost technique capable of showing the 

vascularization of the stomach in real time and its application to the gastroesophageal 
junction (GE) during LSG seems very promising [17-19]. 
In this article, we present a case report of a 40-year-old female with a positive 
intraoperative indocyanine green test as a prediction of the leak after sleeve gastrectomy. 
 
CASE PRESENTATION 
 
A 40-year-oldfemale with a body mass index of 43,1 Kg/m2 and weighing 115 Kg 
underwent laparoscopic sleeve gastrectomy. Her past medical history includes 
hypertension, hypothyroidism with Basedow's disease, left eye glaucoma, depressive 
disorder.During the operation after four port placement, detachment from the great 
curvature with dissection of the gastroepiploic and short gastric vessels was performed 
employing an energy device. 
The sleeve resection was shaped around a 40-French bougie in place using a mechanical 
linear stapler; 5 ml of ICG were then injected intravenously to identify the stomach, 
carefully assessing the angle of His (preoperative written informed consent was obtained 
from the patient). 
Adequate perfusion was defined as “the direct and clear visualization of the fluorescence 
around the gastric tube, after an estimated time of 150-180 s following i.v. 
administration". 
Intraoperative indocyanine green test showed a small dark area at the proximal third of 
the staple line, therefore it was decided to reinforce the suture line using fibrin glue 
(Figure 1a – 1b). 
She had a smooth recovery with discharge home on the second postoperative day after a 
negative Gastrografin swallow test (Figure 2).  
Two weeks later the patient presented to emergency department (ED) with abdominal 
pain, fever, vomiting and intolerance to oral intake. Her laboratory workups were within 
normal, computed tomography (CT) abdomen with oral and intravenous (IV) contrast 
revealed a collection  13x9 cm with air pocket adjacent to the staple line at the upper 
stomach (Figure 3). 

The collection was treated with the placement of two abdominal drainages with 
laparoscopic approach and a self-expanding covered prosthesis placed with endoscopic 
technique to exclude the fistula (Figure 4-5). The patient was discharged in good general 
conditions, normal laboratory tests, control CT showing a clear reduction of the intra-
abdominal collection (Figure 6). The patient will undergo a replacement of the 
prosthesis in 3/4 weeks. 
 
DISCUSSION 
 
The esophagogastric junction represents an anatomical area of weakness for any 
digestive suture. The fundic wall is thinner, and vascularization is more precarious than 
the rest of the stomach. This area under the cardia is more sensitive to technical failure 
or to any increase in intragastric pressure [20]. Experience showed us that almost all 
leaks after bariatric surgery originate in this location, namely just below the GE junction 
[21]. 
The gastric leakage could be due to the creation of a long and narrow tube with the 
maintenance of the pylorus which surely increases the intraluminal pressure (intragastric 
hypertension) or to the localized ischemia related to the gastroepiploic and the ligation 
of the short gastric vessel during the detachment a greater curvature or even an 
inadequate and abnormal inflammatory response to the surgical procedure [22, 23]. 
Recently, much interest has been focused on the possibility of assessing blood supply 
during surgery with the use of ICG fluorescence angiography, which is a real-time, 
inexpensive and feasible method of establishing vascularity in an selected area. [24,25]. It 
has been fully and positively approved in most laparoscopic procedures [26] but there is 
still little literature on its usefulness in bariatric procedures. 
Di Furia et al. led a study on 43 patientsand concluded that intraoperative view of the 
blood supply of the stomach does not appear to represent a prognostic factor for the 
risk of gastric leakage, suggesting a complex multifactorial etiology (intragastric 
hypertension? Abnormal inflammatory response?) Which needs further data to be 
established[27]. 

Ortega et al. have obtained satisfactory results on 86 patients showing that ICG 
fluorescence angiography allows to determine the increased blood supply to the 
proximal stomach before any dissection during sleeve gastrectomy, so that an effort can 
be made to avoid unnecessary injury to these vessels during the procedure[28, 29]. 
Frattini et al. in their preliminary experience, the results of the ICG resemble the 
intraoperative methylene blue test and the postoperative contrast swallow test. The ICG 
allows for real-time assessment and provides a direct picture of tissue perfusion and 
vascularity. Furthermore, IGF may be useful in explaining the exact pathogenesis of 
gastric leak[30]. 
 
CONCLUSIONS 
 
Intraoperative ICG test can be helpful in determining which patients are at greater risk 
of the leak and, more importantly, the cause of the leak. In this case the fibrin glue was 
not sufficient to avoid the gastric fistula, but other reinforcement methods could be 
implemented in case of inadequate perfusion found with the ICG test, such as sutures. 
Further tests are needed to determine if the ICG predicts leak due to ischemia. 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
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DECLARATIONS  
 

Ethics approval and consent to participate: The ethics committee (DDG n. 363 del 
25/10/2016 e s.m.i. DDG n. 318 del 14/06/2019) of our institution (PoliclinicoRiuniti) 
approved the study. 
All research methods were carried out in accordance with relevant guidelines and 
regulations. 
Written informed consent was obtained. 
 
Consent for publication: Not Applicable. 
 
Availability of data and materials: All data generated or analysed during this study are 
included in this published article. 
 
Competing interests: The authors declare no competing interests. 
 
Funding: No funding 
 
Authors' contributions:  
 
GIOVANNA PAVONE and NICOLA TARTAGLIA performed the study conception 
and design. 
MARIO PACILLI, FRANCESCA MADDALENA and FABIO PETRUZZELLI 
analysed and interpreted the data. 
GENNARO MARTINES and MICHELE DE FAZIO contributed to acquisition of 
the data. 
ANTONIO AMBROSI revised the manuscript. 
 
 
 
Figure 1a: Evaluation of perfusion of staple line of the stomach by using Indocyanine green test 
Figure 1b: Intraoperative picture of the staple line of the stomach 
Figure 2: Gastrografin swallow test 

Figure 3: The collection and the air pocket adjacent to the staple line at the upper stomach on the abdominal CT 
Figure 4: The endoscopic evidence of the gastric fistula 
Figure 5: Self-expanding covered prosthesis placed to exclude the fistula 
Figure 6: Control abdomen CT that shows a clear reduction of the intra-abdominal collection