الفهرس 
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Abstract
Morbid obesity is one of the major health problems of the 21st century which has a steadily increasing incidence, representing approximately 10% of the world‘s population and considered as the second leading cause of preventable death after smoking. Annually, obesity-related diseases account for 400,000 of premature deaths.
Management of Obesity can be done by many possible ways like diet regimens, physical exercises, pharmacological, surgical management (Bariatric Surgery) or combinations of any of them together, but current medical therapies for the obesity remain inadequate and bariatric surgery is more effective in achieving weight loss in adults with obesity than nonsurgical weight loss interventions and because of that bariatric surgery is currently the only effective treatment for morbid obesity.
Surgical management includes: purely restrictive operations, purely malabsorptive (which have been abandoned due to severe side effects) and combined procedures.
Gastric restrictive procedures currently include laparoscopic adjustable gastric banding and sleeve gastrectomy, but the placement of an implantable device or the irreversible resection of gastric tissue has limited the acceptance of these procedures by some patients, referring physicians, and surgeons that is why gastric plication surgery has quickly gained interest as it only involves shape modification of the stomach with suture materials to achieve restriction of its capacity.
Leaks are the second most common cause of post GB mortality after pulmonary embolism, and can be associated with significant morbidity prevention and early detection may limit both morbidity and mortality.
Leaks of anastomotic lines are a known problem in both gastric bypass and gastric sleeve procedures. The incidence varies between 2% and 3% depending on procedure and technique used.
The etiology of leakage is probably multifactorial. The common possible causes include technical error including insufficient staple height in the linear or circular stapler (especially during revisional surgery because the gastric wall can be thicker), insufficient suture lines, tearing at the top of suture line (with double loop technique in which the jejunum is divided after construction of the GJA), or ischemic error caused by division of jejunal mesentery or gastric pouch vessels and leaking cautery currents, causing diathermy effects around the staples.
Recognition of an ASL in the bariatric patient can be difficult because the frequent lack of clinical findings in the morbidly obese patient. The impact of an unrecognized leak is potentially devastating. Generalized sepsis and mortality rates which exceed 50% are reported after unrecognized ASL.
As expected, the most common presentations (fever, tachycardia, and tachypnea) were not specific. This raises the importance of suspicion for diagnosis of this potentially lethal complication.
Routine UGI contrast study after laparoscopic mini gastric bypass has greater sensitivity than clinical signs for detecting gastrojejunal leak. Delay in the diagnosis of leakage can impact mortality, and this suggests that indication for routine UGI still exist. Tachycardia is not a reliable early marker of leak in addition to vital signs, including patient medical history or intraoperative events, which should prompt routine postoperative UGI.
The key to manage a leak is early diagnosis and return to operating room for exploration. Delay results in increased morbidity and mortality.
Treatment often depends on the clinical situation present. If the leak is well contained and the patient is haemo-dynamically stable, the patient can be treated conservatively with nothing per mouth percutaneous drainage, intravenous antibiotics, and intravenous nutrition. If the leak is not well contained and the patient is haemodynamically stable, laparoscopic exploration or stent via endoscope or intervention radiology is warranted. If the patient is haemodynamically compromised, open exploration should be performed. During exploration, whether open or laparoscopic, there are 3 principles that must be addressed at the time of exploration: repair of the leak, drain placement, and placement of gastrostomy tube in bypassed stomach.
There are important measures to decrease the incidence of leakage, surgeon preparation is an important key to success with this challenging, advanced laparoscopic procedure. The surgeon must be familiar with management of a bariatric patient, including appropriate indications for surgery, preoperative evaluation, perioperative management, and long term follow up care. Advanced laparoscopic skills, including two handed technique and laparoscopic stapling and suturing, are required. Both fundamentals of bariatric surgery and advanced laparoscopic surgery should be mastered before performing laparoscopic surgery, several intraoperative techniques have been implanted to prevent the anastomosis leak. These interventions include intraoperative pneumatic testing, the use of linear staplers with shorter stapler height, oversewing of staple line, use of omental wrap, and measures designed to reinforce staple line, such as fibrin glue, peristrips, seamguard, bovine pericardium and various other staple line reinforcement material.