Bleeding post LSG occurs, in the majority of cases, from the staple line, but may result from the resected greater omentum [6]. Some signs that aid in early recognition are hematemesis, blood loss through the nasogastric tube/drain (NG) and melena in stools[4] Clinical symptoms and signs of tachycardia (heart rate >100), pain, fever, hypotension (systolic blood pressure <100), mean hemoglobin count that has dropped at least 2 g/dl from what it was prior to the procedure should increase clinical suspicion of bleeding or staple line leak in the early post-operative period [4, 7].

Bleeding can be divided into intra-luminal and extra-luminal. Intraluminal bleeding presents as early hemorrhage, and it is the result of bleeding from the staple line, vessels nearby and gastric ulcers [8]. Early bleeding post-surgery is possibly due to technical failure in the operation [9]. Intraluminal bleeding from the staple line usually presents with an upper gastrointestinal bleed [9]. Extra-luminal hemorrhage presents in the abdominal cavity and early indication of extra-luminal bleeding will be through the abdominal drain [9]. Usual areas where extra-luminal bleeds occur are at the staple line, spleen, liver, or abdominal wall at trocar port sites [3]. As a result, there is an increased risk of developing hematoma and abscess formation. Early bleeding through drains or NG tube is called a sentinel bleed and it usually can occur within hours of surgery [9].

Acute management for hemorrhage involves fluid resuscitation, strict intake and output monitoring with Foley catheter [2]. Patient should receive adequate blood transfusion to stabilize hemoglobin level. Haemodynamically stable patients can be managed conservatively with serial hemoglobin monitoring and drain output. Majority of acute postoperative bleeds settle with conservative management. If there is clinical suspicion of an ongoing bleed, a Computed Tomography (CT) angiogram can demonstrate collections/hematomas and potentially identify the bleeding vessel. If active bleed is identified, angioembolization can be performed to control bleeding. If patient is unstable to proceed to radiology suite, then in the case of intraluminal bleeding the patient will need urgent endoscopic intervention – oesophagogastroduodenoscopy (OGD). Early endoscopic intervention has to be performed only by a trained bariatric endoscopist. Endoscopic evaluation allows for injection of adrenaline or insertion of clips to stop bleeding if detected. Endoscopic intervention should be attempted in the operating theatre in the event patient becomes unstable, and bleeding cannot be controlled endoscopically so that urgent surgery can be done.

In the case of intra-abdominal bleeding, hemodynamic instability warrants urgent re-operation. Diagnostic laparoscopy is an excellent option to allow direct visualization and to identify the bleeding source. It also allows evacuation of the hematoma and a thorough washout to prevent formation of an abscess. In some cases when no obvious source of bleeding is identified it may be advisable to oversew the entire staple line.

Several techniques have been established to control bleeding intraoperatively to identify the bleeder. One of the common methods used is intraoperative packing to help control bleeding and allow for hemostasis. Packing can be done with inserting a raytex gauze and helps to identify bleeding source. Another technique to help reduce bleeding is to increase abdominal pressure. Suction and irrigation can help to identify a source of bleeding, and allow for the application of a clip.

Various techniques have been developed when it comes to preventing bleeding from the staple line. Studies have shown 60 s of compression time instead of 20 s after closure of the stapler before firing has significantly reduced staple line bleeding [10]. It is extremely important to closely inspect the entire staple line after withdrawal of the bougie. Following these steps should significantly decrease the incidence of bleeding from the staple line. If any minor bleeding is detected in this area post-operatively, it can be easily controlled with small clips. However, post-operative bleeding may also be from the resected area of the omentum and the use of drains may aid in the detection of this type of intra-abdominal bleeding [4]. This will facilitate early treatment and the avoidance of the most serious consequences of bleeding [6].

Staple Line Reinforcement (SLR) is a routinely practiced technique today. Benefits of this has resulted in decreased bleeding and staple line leak postoperatively [3]. Concerns with SLR are that they can increase rate of stricture, increase operative time and costs for patients [3]. Different techniques are used for SLR:

However, caution should be used with over sewing since some studies have shown an increased risk of tearing and bleeding at the point of suture penetration when using this technique [8]. Intraoperative placement of drain will help to identify intra-abdominal bleeding. Added benefits of drain placement include identification of leak, may allow converting a leak to a controlled fistula and allows removal of contaminated fluid for prevention of abscess formation [4].

Haemorrhage after sleeve gastrectomy can be intra-luminal or extra-luminal. While bleeding at the site of stapling is best treated by prevention during the surgical procedure, management of upper gastrointestinal bleeding requires a close monitoring and multidisciplinary care. If bleeding is suspected, it can be confirmed by endoscopy or contrast enhanced CT angiogram. Management of bleeding may include surgery or more conservative techniques such as fluid resuscitation and/ or blood transfusion. With proper surgical techniques and through prompt detection and treatment, bleeding following bariatric surgery can be minimized or even avoided.