A gastric leak is the most serious complication and can be classified into acute, early, late, and chronic leaks if the presentation is within one week, one to six weeks, six to 12 weeks, and more than 12 weeks, respectively [10]. It is more common in the immediate postoperative period due to mechanical causes such as stapler misfiring or ischemic causes such as electrocautery dissection [11]. Distal gastric stenosis can impair gastric emptying, causing gastric distension and increased intraluminal mechanical pressure on the staple line [11]. Although the incidence ranges from 0.5% to 5%, gastric leak is associated with higher morbidity and mortality rates of up to 30% [7,12]. If chronic and untreated, the gastric leaks can progress to fistulas. Depending on their location, gastro-colic or esophagopleural-bronchial fistulas may develop [12]. 

Clinical symptoms of gastric leak may vary from asymptomatic to sepsis, multiorgan failure, and death. Upper gastrointestinal (UGI) fluoroscopy and computed tomography (CT) are reliable imaging modalities in identifying the location of the gastric leak, and the latter has the advantage of identifying additional complications such as peri-gastric collections or abscess formations. Leaks are more common along the proximal end of the staple line close to the gastroesophageal junction [13]. These manifest on the UGI fluoroscopy as extraluminal extravasation of water-soluble contrast material. If the leak is not identified with water-soluble contrast, then a high-density barium contrast can identify subtle leaks [13]. CT can help visualize the leaks not evident on UGI fluoroscopy and identify intra-abdominal fluid collections if present [14]. It is crucial to mention the location, extent, and severity of gastric leaks in the radiology report, which affects clinical management. The imaging findings can vary from phlegmonous changes, fluid collection with gas locules, contrast leak into the collection, and contrast leak into intraperitoneal space.

In our case report, the patient developed a gastric leak after a month of marijuana use. The temporal relationship between the onset of the gastric leak and the patient's initiation of marijuana use led us to suspect that it may be a contributing risk factor. Marijuana is the most commonly used recreational drug in the United States, according to the 2016 National Survey on Drug Use and Health [15]. More than 10% of the population reported its monthly usage in a 2017 survey [16]. In addition, the legalization of marijuana in some of the states in the US has increased its usage prevalence further, with every one in 10 people who use marijuana becoming addicted to it [16,17].

Several studies have identified smoking as a risk factor for delayed postoperative gastric leaks after LSG. For instance, Gluszynska et al. included 610 patients who underwent LSG and studied the risk factors for short-term and long-term postoperative complications [18]. The authors reported that nicotine is one of the independent risk factors associated with both short-term and long-term complications [18].

Very few studies are available describing the relation between marijuana use and post-LSG complications. Shockcor et al. studied 71 marijuana users and 71 control patients who underwent bariatric surgery [15]. The authors described that the patients in the marijuana group had a lower rate of long-term follow-up relative to the control group. The study also reported no statistically significant difference in the 30-day outcome between the cases and controls regarding the infection, bleeding, readmission, and reoperation rates [15]. However, the direct impact of marijuana on delayed gastric leaks is less clear. Further studies with a larger patient population are required to study the LSG complications secondary to marijuana use.

The management of gastric leak depends on the hemodynamic status of the patient. Patients with high clinical suspicion of gastric leak and hemodynamic instability must undergo surgical exploratory laparotomy despite negative imaging findings [11]. The management of clinically stable patients depends on the timing of gastric leak. Immediate surgical intervention with lavage and drainage with or without oversewing is recommended for leaks during the postoperative day (POD) 0-4 [11]. For leaks at >POD 4, the patients can be managed conservatively with intravenous hydration, proton pump inhibitors, broad-spectrum antibiotics, and imaging as required [11]. Surgical management can be considered if there is no clinical improvement or clinical deterioration [11].