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Pope R, English W, Walden RL, Bradley E, Spann M, Ardila-Gatas J, Broucek J, Williams B, Samuels JM. Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series. Am Surg 2024; 90:810-818. [PMID: 37927010 DOI: 10.1177/00031348231209533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Perforated marginal ulcers (PMUs) are a rare but known complication of bariatric surgery. Management typically involves prompt surgical intervention, but limited data exists on non-operative approaches. This study reviews published data on non-operative management of PMUs and presents a case series of patients who were managed non-operatively. Our hypothesis is that certain patients with signs of perforation can be successfully managed non-operatively with close observation. METHODS We completed a systematic review searching PubMed, Embase, Web of Science, Cochrane, and clinicaltrials.gov. Ultimately 3 studies described the presentation and non-operative management of 5 patients. Additionally, we prospectively collected data from our institution on all patients who presented between Dec. 2022 and Dec. 2023 with PMUs confirmed on imaging and managed non-operatively. RESULTS In our literature review, three patients had Roux-en-Y gastric bypass (RYGB), while two had one anastomosis gastric bypass. One patient required surgery two days after admission. Another underwent elective conversion surgery weeks later for a non-healing ulcer. Two received endoscopic interventions. One patient recovered with nil-per-os (NPO) status, and intravenous proton pump inhibitor (PPI) treatment. The patients in our case series presented with normal vital signs, an average of 30 months after RYGB, and with CT scan signs of perforation. None of these patients required surgical or endoscopic intervention. CONCLUSION In conclusion, while perforated marginal ulcers have traditionally been considered a surgical emergency, some patients can be successfully treated with non-operative management. More research is needed to identify the clinical presentation features, comorbidities, and imaging findings of this group.
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Affiliation(s)
- Rand Pope
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wayne English
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rachel L Walden
- Eskind Biomedical Library, Vanderbilt University, Nashville, TN, USA
| | - Emma Bradley
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Spann
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica Ardila-Gatas
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph Broucek
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brandon Williams
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason M Samuels
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Verras GI, Mulita F, Lampropoulos C, Kehagias D, Curwen O, Antzoulas A, Panagiotopoulos I, Leivaditis V, Kehagias I. Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients. J Pers Med 2023; 13:1422. [PMID: 37763189 PMCID: PMC10532722 DOI: 10.3390/jpm13091422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/26/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.
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Affiliation(s)
- Georgios-Ioannis Verras
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
| | | | - Dimitrios Kehagias
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
| | - Oliver Curwen
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Andreas Antzoulas
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Ioannis Panagiotopoulos
- Department of Cardiothoracic Surgery, General Hospital of Athens “Ippokrateio”, 11527 Athens, Greece
| | - Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, Westpfalz-Klinikum, 67655 Kaiserslautern, Germany
| | - Ioannis Kehagias
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
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3
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Medas R, Rodrigues-Pinto E. Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks. Gastroenterol Res Pract 2023; 2023:9712555. [PMID: 37342388 PMCID: PMC10279499 DOI: 10.1155/2023/9712555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/20/2022] [Accepted: 11/25/2022] [Indexed: 06/22/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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4
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Rosianu CG, Hoara P, Achim F, Birla R, Bolocan A, Mohssen A, Copca N, Constantinoiu S. The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review. Life (Basel) 2023; 13:life13040966. [PMID: 37109495 PMCID: PMC10144597 DOI: 10.3390/life13040966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives. MATERIALS AND METHODS We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022. RESULTS The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure. CONCLUSIONS Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.
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Affiliation(s)
- Cristian Gelu Rosianu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Petre Hoara
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Florin Achim
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Rodica Birla
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Alexandra Bolocan
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ahmed Mohssen
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Narcis Copca
- Second Department of Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
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5
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De Simone B, Chouillard E, Ramos AC, Donatelli G, Pintar T, Gupta R, Renzi F, Mahawar K, Madhok B, Maccatrozzo S, Abu-Zidan FM, E Moore E, Weber DG, Coccolini F, Di Saverio S, Kirkpatrick A, Shelat VG, Amico F, Pikoulis E, Ceresoli M, Galante JM, Wani I, De' Angelis N, Hecker A, Sganga G, Tan E, Balogh ZJ, Bala M, Coimbra R, Damaskos D, Ansaloni L, Sartelli M, Pararas N, Kluger Y, Chahine E, Agnoletti V, Fraga G, Biffl WL, Catena F. Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines. World J Emerg Surg 2022; 17:51. [PMID: 36167572 PMCID: PMC9516804 DOI: 10.1186/s13017-022-00452-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/16/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. METHOD A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. CONCLUSIONS The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France.
| | - Elie Chouillard
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France
| | - Almino C Ramos
- GastroObesoCenter Institute for Metabolic Optimization, Sao Paulo, Brazil
| | - Gianfranco Donatelli
- Interventional Endoscopy and Endoscopic Surgery, Hôpital Privé Des Peupliers, Paris, France
| | - Tadeja Pintar
- Department of Abdominal Surgery, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Rahul Gupta
- Division of Minimally Invasive Surgery and Bariatrics, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Federica Renzi
- General Surgery and Trauma Team, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milano, Milan, Italy
| | - Kamal Mahawar
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Brijesh Madhok
- East Midlands Bariatric and Metabolic Institute, University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | - Stefano Maccatrozzo
- Department of Bariatric Surgery, Istituto Di Cura Beato Matteo, Vigevano, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Salomone Di Saverio
- Department of Surgery, Madonna Del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Andrew Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Francesco Amico
- Department of Surgery, John Hunter Hospital and The University of Newcastle, Newcastle, MSW, Australia
| | - Emmanouil Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Joseph M Galante
- University of California, Davis 2315 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Nicola De' Angelis
- Service de Chirurgie Digestive Et Hépato-Bilio-Pancréatique - DMU CARE, Hôpital Henri Mondor, Paris, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Edward Tan
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Dimitrios Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, Pavia, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Nikolaos Pararas
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Elias Chahine
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France
| | - Vanni Agnoletti
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Gustavo Fraga
- School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Walter L Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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6
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Badurdeen DS, Lamond K, Gandsas A, Kumbhari V. Endoscopic strategies for the treatment of postbariatric surgery leaks and fistulas. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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El Kary N, Chahine E, Moryoussef F, Vitte RL, Chouillard MA, Gumbs A, Chouillard E. Esophageal Stricture Due to a Self-Expandable Metal Stent (SEMS) Placement for Post Sleeve Gastrectomy Leak: a Case Report. Obes Surg 2019; 29:1943-1945. [PMID: 30900151 DOI: 10.1007/s11695-019-03835-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Nader El Kary
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
- Service de Chirurgie Générale et Digestive, Centre Hospitalier de Poissy-Saint Germain, 10 rue du Champ Gaillard, 78300, Poissy, France
| | - Elias Chahine
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France.
- Service de Chirurgie Générale et Digestive, Centre Hospitalier de Poissy-Saint Germain, 10 rue du Champ Gaillard, 78300, Poissy, France.
| | - Frédérick Moryoussef
- Department of Gatsroenterology and Liver Disease, Interventional Endoscopy Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - René-Louis Vitte
- Department of Gatsroenterology and Liver Disease, Interventional Endoscopy Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - Marc-Anthony Chouillard
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - Andrew Gumbs
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - Elie Chouillard
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
- Service de Chirurgie Générale et Digestive, Centre Hospitalier de Poissy-Saint Germain, 10 rue du Champ Gaillard, 78300, Poissy, France
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8
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Johansen CD, Norum J, Engebretsen BE, Agledahl U. A nutrition problem solved by a two-step endoscopic removal of a non-adjustable gastric band. J Surg Case Rep 2018; 2018:rjy306. [PMID: 30443320 PMCID: PMC6232287 DOI: 10.1093/jscr/rjy306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/27/2018] [Indexed: 11/14/2022] Open
Abstract
Bariatric surgery is an effective approach for weight loss and short-term improvement in metabolic disorders. Stenosis is a common complication of gastric banding. Balloon dilatation or gastrotomy has been employed in this setting. Few studies have indicated endoscopic removal of the band a feasible procedure. We present a 60-year-old female who underwent gastric banding in 1985 and suffered from late stenosis and malnutrition. Endoscopy revealed a severe stenosis. A two-step procedure was performed. Initially a coated stent was placed into the stenosis to achieve pressure necrosis. Two weeks later, the stent was removed and the band was removed endoscopically. The procedure was performed without any complications. The patient was discharged the next day. A follow-up after 2 months revealed no problems with stenosis or malnutrition. The procedure was a safe, efficient and convenient way of handling late stenosis after gastric banding.
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Affiliation(s)
| | - Jan Norum
- Department of Surgery, Finnmark Hospital, Hammerfest, Norway.,Department of Clinical Medicine, Faculty of Health Science, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Bernt E Engebretsen
- Department of Surgery, Finnmark Hospital, Hammerfest, Norway.,Department of Clinical Medicine, Faculty of Health Science, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Uwe Agledahl
- Department of Surgery, Finnmark Hospital, Hammerfest, Norway
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9
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Tasleem SH, Inayat F, Ali NS, Sattar SBA, Munir A, Zafar F. Small Bowel Perforation Secondary to Esophageal Stent Migration: A Comparative Review of Six Cases. Cureus 2018; 10:e3455. [PMID: 30564534 PMCID: PMC6298618 DOI: 10.7759/cureus.3455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although it is a safe and effective method, complications are increasing the morbidity and mortality rate. Small bowel perforation as a result of esophageal stent migration is a remarkably rare occurrence. We report one case from our clinical experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of six cases were found accessible. Abdominal pain was the common clinical presentation. The mean time from stent placement to perforation was 3.4 months (range, two weeks to 12 months). The jejunum was the frequently perforated portion of the small bowel. Surgical intervention was the mainstay of treatment. This comparative review illustrates that clinicians should remain vigilant for small bowel perforation in patients with esophageal stent placement. Further studies are required to delineate the magnitude and scope of this association.
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Affiliation(s)
- Syed H Tasleem
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, USA
| | - Faisal Inayat
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | | | | | - Ahmed Munir
- Internal Medicine, Services Institute of Medical Sciences, Lahore, PAK
| | - Fahad Zafar
- Internal Medicine, King Edward Medical University, Lahore, PAK
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10
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Inversion Technique for the Removal of Partially Covered Self-Expandable Metallic Stents. Obes Surg 2017; 28:161-168. [DOI: 10.1007/s11695-017-2811-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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11
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Périssé LGS, Périssé PCM, Bernardo Júnior C. Endoscopic treatment of the fistulas after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Rev Col Bras Cir 2017; 42:159-64. [PMID: 26291256 DOI: 10.1590/0100-69912015003006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 09/10/2014] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE to evaluate the use of endoscopic self-expandable metallic prostheses in the treatment of fistulas from sleeve gastrectomy and Roux en y gastric bypass. METHODS all patients were treated with fully coated auto-expandable metallic prostheses and were submitted to laparoscopic or CT-guided drainage, except for those with intracavitary drains. After 6-8 weeks the prosthesis was removed and if the fistula was still open a new prostheses were positioned and kept for the same period. RESULTS the endoscopic treatment was successful in 25 (86.21%) patients. The main complication was the migration of the prosthesis in seven patients. Other complications included prosthesis intolerance, gastrointestinal bleeding and adhesions. The treatment failed in four patients (13.7%) one of which died (3.4%). CONCLUSION endoscopic treatment with fully coated self-expandable prosthesis was effective in treating most patients with fistula after sleeve gastrectomy and roux en y gastric bypass.
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Affiliation(s)
| | | | - Celso Bernardo Júnior
- Hospital Universitário Gaffrée e Guinle, Universidade Federal do Estado do Rio de Janeiro, RJ, BR
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12
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Singer JL, Aryaie AH, Fayezizadeh M, Lash J, Marks JM. Predictive Factors for the Migration of Endoscopic Self-Expanding Metal Stents Placed in the Foregut. Surg Innov 2017; 24:353-357. [PMID: 28385100 DOI: 10.1177/1553350617702026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND With recent advancements in endoscopy, self-expandable metal stents (SEMS) have been used to treat gastrointestinal leaks, perforations, and strictures. Stent migration frequently complicates management and often requires additional treatments to reach resolution. Our study aimed to determine predictive factors for stent migration. METHODS Consecutive procedures involving SEMS placed with and without fixation after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic, surgical history, rate of stent migration, and stent characteristic data were collected. Rates of stent migration were compared. RESULTS We reviewed 214 consecutive procedures involving stents placed in the foregut. Median duration of stent placement was 4.0 ± 10.3 weeks. Forty-three (20%) stents migrated after placement. Of those, 27 (63%) required stent replacement. Eleven (5%) procedures utilized stent fixation and 203 (95%) did not. Fixation techniques included endoscopic clips (9%), endoscopic sutures (73%), and transnasal sutures (18%). Stent migration rate was not different between those with and those without fixation ( P = .2). Rate of migration was significantly higher in procedures involving fully covered stents ( P < .001). Migration occurred after esophagectomy and gastric bypass ( P < .001 and P < .05, respectively) and in patients with diabetes ( P < .01). CONCLUSIONS A challenge with SEMS use is stent migration. Diabetes and using fully covered stents were associated with migration as were SEMS used to treat complications of esophagectomy and gastric bypass. Stent fixation was not associated with the prevention of stent migration. No pattern was found that favors an approach to reduce stent migration.
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Affiliation(s)
- Jordan L Singer
- 1 University Hospitals Case Medical Center, Cleveland, OH, USA.,2 Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Amir H Aryaie
- 1 University Hospitals Case Medical Center, Cleveland, OH, USA
| | | | - Jon Lash
- 1 University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Jeffrey M Marks
- 1 University Hospitals Case Medical Center, Cleveland, OH, USA
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13
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Joo MK. Endoscopic Approach for Major Complications of Bariatric Surgery. Clin Endosc 2016; 50:31-41. [PMID: 28008162 PMCID: PMC5299989 DOI: 10.5946/ce.2016.140] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022] Open
Abstract
As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.
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Affiliation(s)
- Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul, Korea
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Guzaiz N, Arabi M, Khankan A, Salman R, Al-Toki M, Qazi S, Alzakari A, Al-Moaiqel M. Gastroesophageal stenting for the management of post sleeve gastrectomy leak. A single institution experience. Saudi Med J 2016; 37:1339-1343. [PMID: 27874149 PMCID: PMC5303772 DOI: 10.15537/smj.2016.12.15761] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 09/04/2016] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To retrospectively evaluate the effectiveness of gastroesophageal stenting for post sleeve gastrectomy staple line leaks using removable self-expandable stents. METHODS Between April 2012 and June 2015, 12 consecutive patients (6 males) with mean age of 34 years (21-38 years) presented with staple line leak 1-8 weeks after the operation (mean 2.8 weeks). Patients underwent gastroesophageal stenting by interventional radiology. A total of 23 stents were deployed with mean length of 17.8 cm (7-24 cm) and mean diameter 25.6 mm (18-36 mm). Stent re-insertion was needed in 7 patients (9 procedure), while 6 patients required percutaneous collection drainage and 3 patients required endoscopic glue injection with clipping. Two stent removal procedures were carried out under endoscopic visualization after failed stent capture under fluoroscopy, while the remaining stents were successfully removed by interventional radiology. Results: Stent placement was technically successful in all patients. Stent migration occurred in 6 patients (50%). There is a tendency for stent migration with shorter stent length (R= -0.557, p=0.008). The mean duration of stenting was 60.5 days (14-137 days). All patients underwent stent removal and resumed oral intake with no recurrence of leak at a mean follow up time of 190 days (14-410 days). Complications included gastrointestinal bleeding (n=1), proximal esophageal stricture (n=1) and stent occlusion (n=1). CONCLUSION Gastroesophageal stenting as a primary measure after diagnosis of early post sleeve gastrectomy leak appears to offer a safe and effective alternative option in obviating repeat surgical interventions. Minimally invasive interventions may still be required for the management of persistent leak.
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Affiliation(s)
- Noha Guzaiz
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Mohammad Arabi
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Azzam Khankan
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Refaat Salman
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Al-Toki
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Shahbaz Qazi
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdulmohsin Alzakari
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Mohammad Al-Moaiqel
- From the Department of Medical Imaging (Guzaiz), King Abdulaziz Medical City, Makkah, the Departments of Medical Imaging (Guzaiz, Arabi, Khankan, Salman, Al-Toki, Qazi, Al-Moaiqel) and Surgery (Alzakari), King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
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Eisendrath P, Deviere J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol 2015; 12:701-10. [PMID: 26347162 DOI: 10.1038/nrgastro.2015.151] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Leaks are the most frequent early postoperative complication in the two most popular bariatric procedures, Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy. Multimodal therapy based on self-expandable stent insertion 'to cover' the defect is the most widely documented technique to date with a reported success rate >80%. Additional experimental techniques 'to close' the defect or 'to drain' the paradigestive cavity have been reported with encouraging results. The role of endoscopy in early postoperative bleeding is limited to management of bleeds arising from fresh sutures and the diagnosis of chronic sources of bleeding such as marginal ulcer after RYGB. Post-RYGB stricture is a more delayed complication than leaks and the role of endoscopic dilation as a first-line treatment in this indication is well documented. Ring and band placement are outdated procedures for obesity treatment, but might still be an indication for endoscopic removal, a technique which does not compromise further surgery, if needed.
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Affiliation(s)
- Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Jacques Deviere
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
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DaVee T, Irani S, Leggett CL, Berzosa Corella M, Grooteman KV, Wong Kee Song LM, Wallace MB, Kozarek RA, Baron TH. Stent-in-stent technique for removal of embedded partially covered self-expanding metal stents. Surg Endosc 2015; 30:2332-41. [PMID: 26416379 DOI: 10.1007/s00464-015-4475-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/27/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Removal of embedded partially covered self-expanding metal stents (PCSEMS) is associated with an increased risk of adverse events compared with removal of fully covered self-expanding stents (FCSES) due to tissue ingrowth. Successful removal of embedded PCSEMS has been described by the stent-in-stent (SIS) technique. AIMS To report the first US experience from three high-volume quaternary care centers on the safety and efficacy of the SIS technique for removal of embedded PCSEMS. METHODS Retrospective study of outcomes for consecutive patients who underwent the SIS for removal of embedded PCSEMS over a 5-year period. RESULTS Twenty-seven embedded PCSEMS were successfully removed using the SIS technique (100 %) from 25 patients (11 males), median age 65 (range 37-80). All stents were successfully removed in one endoscopic session (no repeat SIS procedures were required for persistently embedded stents). The embedded PCSEMS had been in situ for a median of 76 days (range 26-501). Median SIS dwell time (FCSES in situ of PCSEMS) was 13 days (interquartile range 8-16 days; range 4-212 days). One adverse event (self-limited bleeding) occurred during a median follow-up period of 3 months (range 1-32). No patients died, required surgery, or had long-term disability due to adverse events attributed to the SIS technique. Twelve patients required additional interventions following SIS procedure for persistence or recurrence of the underlying pathology. CONCLUSION When performed by experienced endoscopists, safe and effective removal of embedded PCSEMS can be achieved via the SIS technique.
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Affiliation(s)
- Tomas DaVee
- Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Shayan Irani
- Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | | | | | | | | | | | | | - Todd H Baron
- Gastroenterology, University of North Carolina, Chapel Hill, NC, USA.
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Abstract
PURPOSE OF REVIEW Bariatric surgery is recognized as the most effective treatment against obesity as it results in significant weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. This review illustrates the latest developments in the endoscopic management of bariatric surgical complications. RECENT FINDINGS For successful management of complications, precipitating and perpetuating factors must be addressed in addition to directing therapy at the target pathology. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Chronic proximal staple-line leaks/fistulas frequently do not respond to primary closure with diversion therapy, and a new technique of stricturotomy has been reported to improve outcomes. Innovations in the field of transoral endoscopic instruments have led to the development of a single-session entirely internal endoscopic retrograde cholangiopancreatography by creating a gastrogastric anastomosis. SUMMARY Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention. Computed tomography-guided drainage may be necessary in patients with drainable fluid collections. VIDEO ABSTRACT http://links.lww.com/COG/A11.
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Mathus-Vliegen EMH. The cooperation between endoscopists and surgeons in treating complications of bariatric surgery. Best Pract Res Clin Gastroenterol 2014; 28:703-25. [PMID: 25194185 DOI: 10.1016/j.bpg.2014.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/18/2014] [Accepted: 07/05/2014] [Indexed: 02/09/2023]
Abstract
The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.
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Affiliation(s)
- E M H Mathus-Vliegen
- Academic Medical Centre, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Schiesser M, Kressig P, Bueter M, Nocito A, Bauerfeind P, Gubler C. Successful endoscopic management of gastrointestinal leakages after laparoscopic Roux-en-Y gastric bypass surgery. Dig Surg 2014; 31:67-70. [PMID: 24819500 DOI: 10.1159/000358849] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Management of leakages of the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) can be complex. New endoscopic techniques such as covered stents and over-the-scope clips (OTCs) have been developed and are valuable alternative therapeutic options to reoperation and drainage. The aim of this study was to compare the value of stents and OTCs with surgical treatment options for the therapy of anastomotic leakages after LRYGB. METHODS Results of patients who were treated surgically with reoperation, local irrigation and drain placement (n = 9) were compared with results of patients who were treated endoscopically with stent and/or OTC placement (n = 5). Success rate, length of hospital stay, mortality, number of OTC applications/stent placement and percutaneous drainage placements were analyzed. RESULTS Overall, 14 of 1,046 patients (1.34%) developed a leakage of their gastrojejunal anastomosis after LRYGB between 2000 and 2012. While the success rate in surgically treated patients was 88%, the endoscopic treatment using a sequential approach with stenting, OTC application and percutaneous placement of drainages resulted in a 100% closure rate. The mortality rate and length of stay were not substantially different after both treatment regimens. CONCLUSION Endoscopic management of anastomotic leakages after LRYGB may constitute a valuable alternative therapeutic option to surgical reoperation and drainage placement.
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Affiliation(s)
- Marc Schiesser
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Vasilikostas G, Sanmugalingam N, Khan O, Reddy M, Groves C, Wan A. ‘Stent in a Stent’—An Alternative Technique for Removing Partially Covered Stents Following Sleeve Gastrectomy Complications. Obes Surg 2013; 24:430-2. [DOI: 10.1007/s11695-013-1163-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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