Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment

Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos)

BACKGROUND AND AIMS

As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type.

METHODS

The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized.

RESULTS

Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving.

CONCLUSIONS

Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.

Evaluation of the rate of marginal ulcer formation after bariatric surgery using the MBSAQIP database

BACKGROUND

Marginal ulcer (MU) formation is a known problem after gastric bypass. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database contains data from all US and Canadian Centers of Excellence including complication rates. We hypothesized that the short-term rate of ulceration is low.

METHODS

We queried the MBSAQIP database for the year 2015. We searched patients with primary gastric bypass who developed MU. We then compared preoperative, operative, and postoperative characteristics with patients who did not develop MU.

RESULTS

The incidence of MU in the entire cohort of GB patients was 155 of 44,379 (0.35%, 95% CI 0.297%, 0.409%). Among the 155 patients with an ulcer, 88 (57%) patients had only one procedure, 69 had an intervention (therapeutic or diagnostic endoscopy), 16 had readmission, and 3 had reoperation. 65 patients (42%) had two procedures with the majority having both readmissions and endoscopy (n = 59); and two patients (1%) had three procedures. Ulcer formation was most common in the intervention group (11.4%). The occurrence of ulcer formation was associated with unplanned ICU admissions (6.45%), transfusions (5.16%), postoperative UTI (3.87%), sepsis (1.94%), and myocardial infarction (0.65%). Death occurred in 76 patients with no related cases to MUs. The risk of ulcer was associated with increased BMI (OR 1.02, p = 0.01), presence of percutaneous transluminal cardiac catheterization (PTC) (2.17, p = 0.038), histories of DVT (1.72, p = 0.085), and pulmonary embolism (2.84, p = 0.002).

CONCLUSIONS

In a nationally reported database, symptomatic MUs rarely occur in the first month. The large majority are diagnosed and treated endoscopically with minimal need for surgical intervention. The risk of anastomotic ulcer was increased with increased BMI, need for PTC, and history of DVT/PE.

Endoscopic Evaluation and Treatment of Postoperative Bariatric Surgery Complications

The number of patients undergoing bariatric surgery continues to increase. The American Society for Metabolic and Bariatric Surgery (ASMBS) estimates the number of bariatric surgical procedures performed increased from 158 000 in 2011 to 190 000 in 2015. Concurrently, the incidence of postoperative complications specific to bariatric patients will inevitably increase as well. Endoscopic evaluation of postoperative bariatric patients and endoscopic interventions are rapidly evolving. We present a review of the postoperative anatomy of bariatric patients, what complications to expect, and treatment options.

Comparison of marginal ulcer rates between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

Marginal ulcer can be a serious complication after laparoscopic gastric bypass surgery. The aim of this study was to compare the rates of marginal ulcer between the antecolic and the retrocolic technique, in a large cohort of patients.

PATIENTS AND METHODS

Over a near 10-year period, 1,142 patients underwent laparoscopic gastric bypass surgery. The antecolic and the retrocolic technique were used in respectively 572 and 570 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy.

RESULTS

Patients were followed for 18 to 99 months (mean 48.8 months). During follow-up, 46 patients developed a marginal ulcer (4 %), 32 in the antecolic group (5.6 %) and 14 in the retrocolic group (2.5 %). Nineteen patients (3.3 %) in the antecolic group and eight patients in the retrocolic group (1.4 %) developed early marginal ulcer (i.e., within 3 months after surgery). The mean time to onset of anastomotic ulcer symptoms after surgery was 11 months (range 0.25-72). Forty-four patients were submitted to medical treatment, and 35 patients (79.5 %) had complete resolution of their symptoms.

CONCLUSION

Patients with an antecolic Roux limb develop significantly more marginal ulcers (p = 0.007) and early marginal ulcer (p = 0.033) than the patients with a retrocolic Roux limb. The antecolic technique seems to be a risk factor for appearance of marginal ulcer.

[Bursting pressure comparison between stapler and staple line reinforcement with sutures and butress biologic material: an experimental study]

BACKGROUND

Staple line leaks carry significant morbidity and mortality. Reinforcement is controversial. Several staple techniques have been described for this purpose. Oversuture and butressing material are more common.

AIM

To compare these two ways of reinforcement and staple line without any reinforcement regarding the bursting pressure.

METHOD

Ten segments of small bowel were created in a pig under general anesthesia. The bowel was inflatted until burst point and the pressure was measured.

RESULTS

The staple line bursting pressure was 94 mmHg +/- 18,52mmHg in the stapler technique; 87,5 mmHg +/- 18,59mmHg in the oversuture and 83,33 mmHg +/- 23,04mmHg with Surgisis®. There was no statistic difference among the techniques.

CONCLUSIONS

Oversuture or Surgisis® use did not increase the staple line resistance in pig.

Endoscopic management of complications after gastrointestinal weight loss surgery

As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.

Endoscopic management of common bariatric surgical complications

The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation. Endoscopists caring for these patients should become familiar with post-bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal/extra-luminal findings, and endoscopic management of common bariatric complications; this review addresses these issues. This review will discuss common presenting symptoms, luminal as well as extra-luminal findings and endoscopic management of common bariatric complications.

Clinical results using bioabsorbable staple-line reinforcement for circular stapler in colorectal surgery: a multicenter study

INTRODUCTION

Anastomotic leakage is a serious postoperative complication of open and laparoscopic colorectal surgery, very often associated with higher morbidity and mortality. Despite proper patient selection and surgical technique, anastomotic leakage cannot be avoided. The use of a synthetic, bioabsorbable staple-line reinforcement material for the circular stapler may help reduce its prevalence.

METHODS

From May to December of 2006, 14 doctors, from 18 hospitals in the United States, performed 117 laparoscopic and open colorectal procedures, in which circular bioabsorbable Seamguard (CBSG; W.L. Gore and Associates, Elkton, MD) was used.

RESULTS

Eighty-three patients underwent laparoscopic surgery (70.0%) and 34 open surgery (30%). The procedures included low anterior resection in 49 patients (42%), sigmoidectomy in 46 patients (39.5%), left hemicolectomy in 12 patients (10%), and total colectomy in 10 patients (8.5%). Sixty-four patients had benign disease and 36% malignant disease. Intraoperative anastomotic leakage tests identified 4 patients with leakage (3.4%). All 4 patients had a very low anastomosis (1, 3, 4, and 6 cm, respectively, from the anal verge). Two of the leaks resolved without further intervention. A fecal diversion procedure was performed in the other 2 patients, including 1 patient with rectal bleeding, requiring a transfusion. No clinical complications related to use of CBSG were reported.

CONCLUSIONS

The use of Seamguard in colorectal open and laparoscopic surgery may result in a lower incidence of anastomotic leakage.

Endoscopic foreign body removal for treatment of chronic abdominal pain in patients after Roux-en-Y gastric bypass

BACKGROUND

Common endoscopic findings in patients who have undergone Roux-en-Y gastric bypass (RYGB) with chronic abdominal pain have included marginal ulceration, gastrogastric fistula, and jejunal erosion. However, suture or staples eroding into the gastric pouch can also contribute to abdominal pain. Redundant suture is typically regarded as a normal part of the postoperative anatomy. The objectives of the present study were to assess the effects of endoscopic foreign body removal of partially exposed sutures and staples in post-RYGB patients with chronic abdominal pain at a university hospital in the United States.

METHODS

We performed a retrospective study of consecutive patients from January 2006 to July 2007. Post-RYGB patients with chronic abdominal pain underwent endoscopic foreign body removal of exposed sutures/staples. Pain scores were obtained before the procedure, immediately after the procedure, and at the telephone follow-up (median 7.2 months).

RESULTS

Of 21 patients, 15 (71%) reported immediate symptomatic improvement. Specific endoscopic accessories were found to be more useful than others in managing the various foreign materials. Of the 21 patients, 15 (71%) were available for telephone follow-up. Of these 15 patients, 13 (87%) reported continued symptomatic improvement, with 9 (60%) reporting complete pain resolution and 4 (27%) reporting partial improvement. Eroded foreign material was seen in association with marginal ulcers in 3 patients (14%), gastritis in 7 patients (33%), and an inflammatory polyp in 1 patient (5%).

CONCLUSIONS

Eroded suture and staples can cause chronic abdominal pain in post-RYGB patients. In symptomatic patients, visible suture or staples should be considered a potential etiology of chronic pain, instead of normal postoperative findings. Endoscopic foreign body removal might be of therapeutic benefit in these patients.

Comparison of permanent and nonpermanent staple line buttressing materials for linear gastric staple lines during laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Several publications have suggested that staple line buttressing might decrease staple line bleeding, increase burst pressure, and decrease the likelihood of acute failure resulting in leak. Currently, permanent and nonpermanent options are available. However, concern has been raised about the permanent buttress material and its potential for delayed strip expulsion. This study analyzed our experience with 3 different buttressing materials for creating the gastric division during laparoscopic Roux-en-Y gastric bypass.

METHODS

From July 5, 2001 to May 30, 2007, 1451 consecutive patients underwent laparoscopic gastric bypass with buttressing material used for the stapled creation of the gastric pouch. Peristrips Dry (PSDs), permanent bovine pericardial strips, were used in 926 cases from July 5, 2001 to October 11, 2005. Seamguards, a synthetic bioabsorbable product, were used in 145 cases from November 2, 2004 to July 18, 2006, and PSD Veritas, remodelable, nonpermanent bovine pericardial strips, were placed in 380 patients from October 11, 2005 to May 30, 2007. All products were applied to the 60-mm-long, 3.5-mm cartridges of the EndoGIA II stapler. The ease of use, operative complications, visual bleeding, and postoperative leaks were recorded.

RESULTS

The patient characteristics were comparable for all groups. All products were easy to load on the stapler, and no operative complications related to the use of the buttress materials occurred. The incidence and severity of staple line bleeding was not specifically calculated but was visually noted to be minimal in all cases. Of the 3 groups, 4 contained leaks occurred in the Seamguards group, and all were successfully managed nonoperatively. No acute leaks were discovered in the PSD or PSD Veritas groups. This difference was statistically significant (p <.001).

CONCLUSION

Neither the PSDs or PSD Veritas group exhibited staple line complications. However, 4 leaks occurred in the patients who had Seamguards incorporated into their gastric pouch linear staple lines.