Endoscopic management of bariatric complications: A review and update

Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery

INTRODUCTION

Roux-en-Y gastric bypass is a commonly used technique of bariatric surgery. One of the most important complications is gastrojejunal anastomotic stricture. Endoscopic balloon dilation appears to be well tolerated and effective, but well-designed randomized, controlled trials have not yet been conducted.

OBJECTIVE

Identify factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery.

SETTING

Gastrointestinal endoscopy service, university hospital, Brazil.

METHODS

The records of 64 patients with anastomotic stricture submitted to endoscopic dilation with hydrostatic balloon dilation were reviewed. Information was collected on gastric pouch length, anastomosis diameter before dilation, number of dilation sessions, balloon diameter at each session, anastomosis diameter after the last dilation session, presence of postsurgical complications, endoscopic complications, and outcome of dilation. Comparisons were made among postsurgical and endoscopic complications; number of dilations, balloon diameter; anastomosis diameter before dilation; and dilation outcome.

RESULTS

Success of dilation treatment was 95%. Perforation was positively and significantly associated with the number of dilation sessions (P = .03). Highly significant associations were found between ischemic segment and perforation (P<.001) and between ischemic segment and bleeding (P = .047). Ischemic segment (P = .02) and fistula (P = .032) were also associated with dilation failure.

CONCLUSION

Ischemic segment and fistula were found to be important risk factors for balloon dilation failure. The greater the number of dilation sessions, the greater the number of endoscopic complications.

Endoluminal vacuum therapy for gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass: a pilot study in a swine model

BACKGROUND

Roux-en-Y gastric bypass (RYGB) consistently produces the most sustainable weight loss among common interventions for morbid obesity. Anastomotic leaks at the gastrojejunal (GJ) connection result in severe morbidity. We apply endoluminal negative pressure vacuum devices (EVD) to heal anastomotic leaks in a swine model.

METHODS

RYGB was performed in 10 pigs (3 control, 7 experimental). GJ anastomoses were fashioned, and a 2-cm defect was made across the staple line. In controls, the defects remained open. In experimental pigs, the EVD was placed across the defect and kept at continuous 50 mmHg suction. All pigs were euthanized on postoperative day seven unless they displayed signs of peritonitis or sepsis. Fluoroscopy and necropsy were performed to assess a persistent leak, and tissue specimens were sent to histology to evaluate for degree of inflammation and ischemia.

RESULTS

All three control pigs' GJ anastomoses demonstrated evidence of a persistent leak. All seven experimental pigs with the EVD in place showed evidence that their leak had sealed at time of fluoroscopy (p value 0.008).

CONCLUSIONS

Endoluminal vacuum therapy is well tolerated in a swine model. GJ anastomotic leaks were consistently sealed with our device in place compared to controls. This therapy shows promise as a method to address GJ leaks in the bariatric population, and thus, we believe additional evaluation is warranted.

Roux-en-Y fistulo-jejunostomy as a salvage procedure in patients with post-sleeve gastrectomy fistula: mid-term results

BACKGROUND

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure in France. It achieves both adequate excess weight loss and significant reduction in comorbidities. However, fistula is still the most common complication after SG, occurring in more than 3 % of cases, even in specialized centers (Gagner and Buchwald in Surg Obes Relat Dis 10:713-723. doi: 10.1016/j.soard.2014.01.016 , 2014). Its management is not standardized, long, and challenging. We have already reported the short-term results of Roux-en-Y fistulo-jejunostomy (RYFJ) as a salvage procedure in patients with post-SG fistula (Chouillard et al. in Surg Endosc 28:1954-1960 doi: 10.1007/s00464-014-3424-y , 2014). In this study, we analyzed the mid-term results of the RYFJ emphasizing its endoscopic, radiologic, and safety outcome.

METHODS

Between January 2007 and December 2013, we treated 75 patients with post-SG fistula, mainly referred from other centers. Immediate management principles included computerized tomography (CT) scan-guided drainage of collections or surgical peritoneal lavage, nutritional support, and endoscopic stenting. Ultimately, this approach achieved fistula control in nearly two-thirds of the patients. In the remaining third, RYFJ was proposed, eventually leading to fistula control in all cases. The mid-term results (i.e., more than 1 year after surgery) were assessed using anamnesis, clinical evaluation, biology tests, upper digestive tract endoscopy, and IV-enhanced CT scan with contrast upper series.

RESULTS

Thirty patients (22 women and 8 men) had RYFJ for post-SG fistula. Mean age was 40 years (range 22-59). Procedures were performed laparoscopically in all but 3 cases (90 %). Three patients (10 %) were lost to follow-up. Mean follow-up period was 22 months (18-90). Mean body mass index (BMI) was 27.4 kg/m(2) (22-41). Endoscopic and radiologic assessment revealed no persistent fistula and no residual collections.

CONCLUSIONS

Despite the lack of long-term follow-up, RYFJ could be a safe and feasible salvage option for the treatment of patients with post-SG fistula, especially those who failed conservative management. Mid-term outcome analysis confirms that fistula control is durable. Weight loss panel is satisfactory.