Over the last decade, there has been increasing use of self-expanding metal stents (SEMS) for the treatment of sleeve leaks. The objective of stenting has been to divert gastric contents from the fistula site and to bypass the distal stenotic portion if present. Casella and colleagues reported the use of endoscopic stents for sleeve leaks in three patients with 100 % success [14]. Oshiro and colleagues reported 100 % success in 2 patients of sleeve leak with covered endoscopic stents. [15]. Nyugen et al. reported 100 % success in three cases treated with endoscopic stenting [16]. Southwell et al. reported 95 % success with endoscopic stenting but significant stent migration in 19 % of primary stents [17]. Serra and colleagues reported on the use of coated self-expanding stents for management of leaks after laparoscopic sleeve gastrectomy (LSG) or duodenal switch in six patients with control of leaks in 83 % of cases [18]. Simon et al. reported 78 % success in patients with gastric staple line leaks after LSG treated with covered stents [19]. Eubanks et al. reported a success rate of 84 % with covered endoscopic stents with a success rate of 84 % for closure of sleeve leaks [20]. Tan et al. reported a success rate of 50 % in 8 cases of sleeve leaks with covered stents, with four patients requiring premature removal of the stent due to migration, hematemesis, and obstruction from kinking at the proximal aspect of the stent [6]. Fukumoto and colleagues reported a single case of endoscopic stent for leak after sleeve gastrectomy without success that required operative closure of the fistula [21].

Thus endoscopic stenting for gastric leaks has a variable success rate which is dependent on medical expertise available. The main advantages in using a stent include bridging the fistula resulting in source control and allowing for early oral nutrition. There exists a wide variation in practice with regards to the type of stent, the length and the diameter of the stent to be used and the number of stenting sessions required. However, it is clear from these series that stent placement is limited by a high rate of migration of around 30–60 %. In majority, the migration is within the stomach but in some cases even small bowel migration needing operative removal has been reported [20]. Thus multiple sessions of stenting could be required in many patients adding to the cost. Various maneuvers have been described to reduce migration with limited success. These include fixing the stent to the sleeve by suturing or using transnasally externalised threads, use of wider stents, use of partially covered stents (Ultraflex Boston Scientific, USA), use of stents with double layer anti-migratory cuffs [Beta stent (Taewoong Medical, Korea)] and use of stents with both a wider diameter and a long body (TaewoongNiti-S™ Megastent) [17]. The Taewoong Niti-S™ Megastent is a recently developed promising stent whose length and wide diameter limits migration. Its length provides effective drainage of the entire sleeve and wide diameter also helps to keep open stenotic areas [22]. Its length however results in its wide distal flare resting at the duodenum which can cause significant mucosal ulceration (decubitus ulcers). It is also not tolerated as well as the other stents. Other less commonly reported complications of stenting include mucosal overgrowth with retrieval problems and persistent vomiting with inability to tolerate the stent [18]. Other endoscopic therapies such as metal clips, over the scope clips (OTSC) and glue injection have been described and can be used as complementary therapy on a case to case basis [23–25].

In summary, endoscopic stent placement has a definite role in the management of sleeve leaks. But this management strategy needs special expertise, multiple sessions, has recognized complications with added costs. Although reasonable success rates have been reported, it still cannot be recommended as a standalone treatment option.

Donatelli et al. recently described the use of endoscopically placed endobiliary catheters with enteral nutrition (EDEN) as an alternative to stenting [26]. These stents are placed through the fistula tract into the collection providing drainage. With time there is a reduction of the cavity size with closure. The author reported closure in 20 out of 21 patients without metallic stents. Though Donatelli et al. reported success with use in varied sized fistulous openings Nedeleu et al. recommended selected use in freely draining fistulae smaller than 10 mm and for leaks larger than 10 mm or of any size in the presence of sleeve stenosis to be managed with SEMS [27].

More definitive surgical options include conversion of the LSG to a regular Roux-Y gastric bypass (RYGB), anastomosis of the jejunal Roux limb to the fistula and total gastrectomy.

Conversion of the sleeve to a RYGB is recommended as a surgical option for sleeve leak. The short distance from the esophagogastric junction to the fistula may not allow pouch construction above the leak in most cases. However the fistulous opening may not necessarily be excluded at the time of the procedure. Praveenraj et al. demonstrated that laparoscopic suturing of the fistulous opening in the remnant pouch with a RYGB leading to closure of the fistula [28, 29]. The authors suggested that converting a sleeve to a RYGB leads to decompression of the high intragastric pressure within the sleeve to a low pressure system. Also a Roux limb allows for better drainage than a sleeve, which can have functional disorders or stenotic areas. Conversion of the LSG to a RYGB may not be advisable in the presence of significant peritonitis.