Management of Staple‑Line Leaks after Laparoscopic Sleeve Gastrectomy: Efficacy of Double Pigtail Stenting and a Practical Algorithm for Early and Late Leaks

Abstract Background: Staple-line leak (SLL) remains one of the most severe complications following laparoscopic sleeve gastrectomy (LSG). Although endoscopic internal drainage using double pigtail stents (DPS) has emerged as an effective minimally invasive treatment, evidence comparing its efficacy according to leak timing remains limited. The aim of this study was to evaluate the clinical outcomes of DPS for the management of SLL after LSG and compare treatment success between early and late leaks. Methods: This retrospective cohort study included consecutive patients referred to a tertiary bariatric referral center with confirmed SLL following LSG. Patients were categorized into early (<7 days) and late (≥7 days) leak groups. All patients underwent multidisciplinary management consisting of resuscitation, nutritional support, antibiotics, radiologic assessment, and endoscopic evaluation. DPS was used whenever technically feasible for internal drainage. Primary outcome was successful leak closure without the need for definitive reconstructive surgery. Secondary outcomes included additional interventions, hospital stay, intensive care unit (ICU) stay, and mortality. Results : Fifty patients with SLL were included (26 early leaks and 24 late leaks). Baseline demographic and clinical characteristics were comparable between groups. DPS placement was attempted in 41 patients. Leak resolution following DPS was significantly higher in late leaks than early leaks (80.0% vs. 52.4%, P =0.031). Early leaks more frequently required radiologic drainage (84.6% vs. 54.2%, P =0.030) and surgical intervention (80.8% vs. 25.0%, P =0.001). The need for definitive reconstructive surgery was also significantly greater in early leaks (53.8% vs. 25.0%, P =0.048). Length of hospital stay, ICU stay, and mortality did not differ significantly between groups. Conclusions: Double pigtail stenting is an effective minimally invasive treatment for staple-line leaks after LSG, particularly in patients with late leaks, where high rates of leak resolution can be achieved while avoiding major revisional surgery. Early leaks remain more challenging and frequently require multimodal management combining endoscopic, radiologic, and surgical approaches. Treatment strategies should therefore be individualized according to leak timing within a multidisciplinary bariatric program.