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Sanz Segura P, Gotor Delso J, García Cámara P, Sierra Moros E, Val Pérez J, Soria Santeodoro MT, Uribarrena Amezaga R. Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:198-203. [PMID: 34052404 DOI: 10.1016/j.gastrohep.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/02/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The use of esophageal stents for the endoscopic management of esophageal leaks and perforations has become a usual procedure. One of its limitations is its high migration rate. To solve this incovenience, the double-layered covered esophageal stents have become an option. OBJECTIVES To analyse our daily practice according to the usage of double-layered covered esophageal metal stents (DLCEMS) (Niti S™ DOUBLE™ Esophageal Metal Stent Model) among patients diagnosed of esophageal leak or perforation. METHODS Retrospective, descriptive and unicentric study, with inclusion of patients diagnosed of esophageal leak or perforation, from November 2010 until October 2018. The main aim is to evaluate the efficacy of DLCEMS, in terms of primary success and technical success. The secondary aim is to evaluate their (the DLCEMS) safety profile. RESULTS Thirty-one patients were firstly included. Among those, 8 were excluded due to mortality not related to the procedure. Following stent placement, technical success was reached in 100% of the cases, and primary success, in 75% (n=17). Among the complications, stent migration was present in 21.7% of the patients (n=5), in whom the incident was solved by endoscopic means. CONCLUSIONS According to our findings, DLCEMS represent an alternative for esophageal leak and perforation management, with a high success rate in leak and perforation resolutions and low complication rate, in contrast to the published data. The whole number of migrations were corrected by endoscopic replacement, without the need of a new stent or surgery.
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Affiliation(s)
- Patricia Sanz Segura
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - Jesús Gotor Delso
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Paula García Cámara
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Eva Sierra Moros
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - José Val Pérez
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
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Mandarino FV, Esposito D, Spelta GNE, Cavestro GM, Rosati R, Parise P, Gemma MF, Fanti L. Double layer stent for the treatment of leaks and fistula after upper gastrointestinal oncologic surgery: a retrospective study. Updates Surg 2021; 74:1055-1062. [PMID: 34510378 DOI: 10.1007/s13304-021-01155-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
Anastomotic dehiscence is one of the most morbidity related and deadly complication after foregut oncologic surgery. The aim of the study is to evaluate the effectiveness of double layer stents (Niti-S™ Beta™ Esophageal Stent) in the management of dehiscences after upper gastrointestinal oncologic surgery. We retrospectively studied consecutive patients who underwent Niti-S™ Beta™ esophageal stent placement from June 2014 to September 2019 for the treatment of anastomotic leaks/fistula following esophagectomy or gastrectomy for cancer. Univariate two-sided logistic regression analysis was used to evaluate possible predictors of successful anastomotic leak/fistula closure. A total of 37 patients were studied and 75 stents were positioned in these patients during the endoscopic procedures. Effective leak/fistula closure was obtained in 23/37 (62.2%). No technical endoscopic failure or complications ensued during the placing of the devices. Regarding delayed complications, migration was observed in 17/75 (22.7%) procedures and stent leaking in 29/75 (38.6%). Three variables significantly favoured stent treatment failure, namely previous neoadjuvant therapy (OR 9.3, P = 0.01), fistula (instead of leak) (OR 6.5, P = 0.01), and stent leak (OR 17.0, P = 0.01). Placement of Beta Niti-S esophageal stent is a safe and effective method that could be considered for the management of leaks and fistula after upper gastrointestinal cancer. Crucial points in the management of post-surgical leaks with this technique are the prompt recognition of leaks and fistula, the prompt endoscopic/radiologic drain of collection and the choice of adequate size of the stent.
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Affiliation(s)
- Francesco Vito Mandarino
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
| | - Dario Esposito
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Greta Natalia Edmea Spelta
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - Giulia Martina Cavestro
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Riccardo Rosati
- Division of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Parise
- Division of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Fabio Gemma
- Department of Anaesthesia and Intensive Care, Fatebenefratelli Hospital, Milan, Italy
| | - Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Hamid HKS, Emile SH, Saber AA, Dincer M, de Moura DTH, Gilissen LPL, Almadi MA, Montuori M, Vix M, Perisse LGS, Quezada N, Garofalo F, Pescarus R. Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis. Surg Endosc 2020; 35:1025-1038. [DOI: 10.1007/s00464-020-08147-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
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Cereatti F, Grassia R, Drago A, Conti CB, Donatelli G. Endoscopic management of gastrointestinal leaks and fistulae: What option do we have? World J Gastroenterol 2020; 26:4198-4217. [PMID: 32848329 PMCID: PMC7422542 DOI: 10.3748/wjg.v26.i29.4198] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.
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Affiliation(s)
- Fabrizio Cereatti
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Roberto Grassia
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Andrea Drago
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Clara Benedetta Conti
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Gianfranco Donatelli
- Department of Interventional Endoscopy, Hospital Prive Peupliers, Ramsay Santé, Paris 75013, France
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Okazaki O, Bernardo WM, Brunaldi VO, Junior CCDC, Minata MK, de Moura DTH, de Souza TF, Campos JM, Santo MA, de Moura EGH. Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2019; 28:1788-1796. [PMID: 29654447 DOI: 10.1007/s11695-018-3236-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.
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Affiliation(s)
- Ossamu Okazaki
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil.
| | - Wanderley M Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Vitor O Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Cesar C de Clemente Junior
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Maurício K Minata
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Diogo T H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Thiago F de Souza
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | | | - Marco Aurélio Santo
- Bariatric and Metabolic Surgery Unit, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Eduardo G H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
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Yu D, Zhou Z, Zhang X. Surgical treatment of the severe thoracic gastrocutaneous fistula by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma: A case report. Int J Surg Case Rep 2019; 55:76-79. [PMID: 30711886 PMCID: PMC6360347 DOI: 10.1016/j.ijscr.2019.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thoracic anastomotic fistula (TAF) is a severe postoperative complication of oesophagectomy, and its occurrence coupled with a thoracic gastrocutaneous fistula (TGCF) and tracheostenosis is very unusual and may lead to a fatal consequence. CASE PRESENTATION We describe a case of an old female diagnosed with mid-oesophageal carcinoma, who presented with a TAF after oesophagectomy, which was healed by an effective treatment, while a severe TGCF and tracheostenosis appeared one month postoperation. The complications were detected by gastroscopy, barium oesophagogram and thoracic computed tomography (CT). Through surgical treatments, including pedicled muscle flap filling and thoracoplasty, and a correlated corrective procedure, the patient completely recovered and was discharged six months after the admission. CONCLUSION Treatment by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma can be a curative alternative for the severe thoracic gastrocutaneous fistula.
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Affiliation(s)
- Dongmin Yu
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Zizi Zhou
- Department of Cardio-Thoracic Surgery, Shenzhen University General Hospital, Shenzhen, China; Department of Plastic and Reconstructive Surgery, BG Unfallklinik Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Xiaoming Zhang
- Department of Cardio-Thoracic Surgery, Shenzhen University General Hospital, Shenzhen, China.
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Gonzalez JM, Lorenzo D, Guilbaud T, Bège T, Barthet M. Internal endoscopic drainage as first line or second line treatment in case of postsleeve gastrectomy fistulas. Endosc Int Open 2018; 6:E745-E750. [PMID: 29876512 PMCID: PMC5988543 DOI: 10.1055/s-0044-101450] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Management of post-sleeve gastrectomy fistulas (PSGF) recently has evolved, resulting in prioritization of internal endoscopic drainage (IED). We report our experience with the technique in a tertiary center. PATIENTS AND METHODS This was a single-center, retrospective study of 44 patients whose PSGF was managed with IED, comparing two periods: after 2013 (Group 1; n = 22) when IED was used in first line and before 2013 (Group 2; n = 22) when IED was applied in second line. Demographic data, pre-endoscopic management, characteristics of fistulas, therapeutic modalities and outcomes were recorded and compared between the two groups. The primary endpoint was IED efficacy; the secondary endpoint was a comparison of outcomes depending on the timing of IED in the management strategy. RESULTS The groups were matched in gender (16 female, 16 male), mean age (43 years old), severity of fistula, delay before treatment, and exposure to previous endoscopic or surgical treatments. The overall efficacy rate was 84 % (37/44): 86 % in Group 1 and 82 % in Group 2 (NS). There was one death and one patient who underwent surgery. The median time to healing was 226 ± 750 days (Group 1) vs. 305 ± 300 days (Group 2) (NS), with a median number of endoscopies of 3 ± 6 vs . 4.5 ± 2.4 (NS). There were no differences in number of nasocavity drains and double pigtail stents (DPS), but significantly more metallic stents, complications, and secondary strictures were seen in Group 2. CONCLUSION IED for management of PSGF is effective in more than 80 % of cases whenever it is used during the therapeutic strategy. This approach should be favored when possible.
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Affiliation(s)
- J. M. Gonzalez
- Aix-Marseille Univ, APHM, Service de gastroentérologie, Hôpital Nord, Marseille, France,Corresponding author Jean-Michel Gonzalez, MD, MSc Service de GastroentérologieHôpital Nord, AP-HMChemin des Bourrelys13015, MarseilleFrance+04 91 96 87 37
| | - D. Lorenzo
- Aix-Marseille Univ, APHM, Service de gastroentérologie, Hôpital Nord, Marseille, France
| | - T. Guilbaud
- Aix-Marseille Univ, APHM, Service de chirurgie digestive, Hôpital Nord, Marseille, France
| | - T. Bège
- Aix-Marseille Univ, APHM, Service de chirurgie digestive, Hôpital Nord, Marseille, France
| | - M. Barthet
- Aix-Marseille Univ, APHM, Service de gastroentérologie, Hôpital Nord, Marseille, France
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Efficacy and Safety of the Over-the-Scope Clip (OTSC) System in the Management of Leak and Fistula After Laparoscopic Sleeve Gastrectomy: a Systematic Review. Obes Surg 2018; 27:2410-2418. [PMID: 28353180 DOI: 10.1007/s11695-017-2651-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. OBJECTIVES This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. METHODS PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. RESULTS A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). CONCLUSION OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.
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Lorenzo D, Guilbaud T, Gonzalez JM, Benezech A, Dutour A, Boullu S, Berdah S, Bège T, Barthet M. Endoscopic treatment of fistulas after sleeve gastrectomy: a comparison of internal drainage versus closure. Gastrointest Endosc 2018; 87:429-437. [PMID: 28750839 DOI: 10.1016/j.gie.2017.07.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 07/19/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Fistulas after sleeve gastrectomy are major adverse events of bariatric surgery. The endoscopic management strategy evolved from closure to internal drainage after 2013. The main objective of our study was to evaluate and compare these different approaches. METHODS This retrospective study included all patients treated for fistulas after sleeve gastrectomy in a referral center. Closure management was defined as initial treatment that used a covered metal stent and/or endoclips. Internal drainage management was defined as initial treatment by nasocystic drain and/or a double-pigtail stent. RESULTS A total of 100 patients (women N = 78, mean [± standard deviation {SD}] age 42 ± 12 years) were included between 2007 and 2015. The mean (± SD) delay between sleeve gastrectomy and the first endoscopy was 82 ± 125 days. The overall success of endoscopic treatment was 86% within 6 ± 27 months. Two patients died. The primary success of internal drainage and closure management occurred in 19 of 22 (86%) and 49 of 77 (63%) patients, respectively. Among patients in failure for closure management, 22 had secondary internal drainage (18 being successful). Success of initial management was significantly higher for internal drainage (P = .043). Factors associated with failure of closure management were in multivariable analysis: collection >5 cm (P = .013). Factors associated with a time >6 months for achieving leakage closure were in multivariable analysis: reoperation before endoscopy (P = .044) and purulent flow at endoscopy (P = .043). CONCLUSIONS Endoscopic management of fistulas after sleeve gastrectomy was successful in 86% of cases. In cases of collections >5 cm, internal drainage should be proposed first. Surgical reintervention before endoscopy delays treatment success.
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Affiliation(s)
- Diane Lorenzo
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Théophile Guilbaud
- Department of Visceral Surgery, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Jean Michel Gonzalez
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Alban Benezech
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Anne Dutour
- Department of Endocrinology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Sandrine Boullu
- Department of Endocrinology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Stéphane Berdah
- Department of Visceral Surgery, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Thierry Bège
- Department of Visceral Surgery, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
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Tellechea JI, Gonzalez JM, Miranda-García P, Culetto A, D'Journo XB, Thomas PA, Barthet M. Role of Endoscopy in the Management of Boerhaave Syndrome. Clin Endosc 2017; 51:186-191. [PMID: 28928355 PMCID: PMC5903076 DOI: 10.5946/ce.2017.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 06/23/2017] [Accepted: 07/03/2017] [Indexed: 11/14/2022] Open
Abstract
Boerhaave syndrome (BS) is a spontaneous esophageal perforation which carries high mortality. Surgical treatment is well established, but the development of interventional endoscopy has proposed new therapies. We expose our experience in a Gastrointestinal and Endoscopy Unit. With a retrospective, observational, open-label, single center, consecutive case series. All patients diagnosed with BS who were managed in our center were included. Treated conservatively, endoscopically or surgically, according to their clinical condition and lesion presentation. Fourteen patients were included. Ten were treated with primary surgery. One conservatively. In total, 7/14 patients required an endoscopic treatment. All required metallic stents deployment, 3 cases over-the-scope-clips concomitantly and one case a novel technique an internal drain. 6/7 cases endoscopically treated achieved complete esophageal healing. In conclusion, endoscopy is an useful tool at all stages BS management: difficult diagnosis, primary treatment in selected patients and as salvage when surgery fails. With mortality rates and outcomes comparables to surgery.
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Affiliation(s)
- Juan Ignacio Tellechea
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Jean-Michel Gonzalez
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Pablo Miranda-García
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Adrian Culetto
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Xavier Benoit D'Journo
- Department of Thoracic Surgical, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgical, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
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Sousa P, Castanheira A, Martins D, Pinho J, Araújo R, Cancela E, Ministro P, Silva A. Treatment of Postoperative Leaks of the Upper Gastrointestinal Tract with Colonic Self-Expandable Metal Stents. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:169-175. [PMID: 29255746 DOI: 10.1159/000453115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/30/2016] [Indexed: 01/28/2023]
Abstract
Introduction The use of self-expandable metal stents (SEMS) for the treatment of postoperative leaks of the upper gastrointestinal tract is already established. However, there are discrepancies between the relatively small caliber of the esophageal stents available and the postsurgical luminal size, which may determine an inadequate juxtaposition. As colonic stents have a bigger diameter, they might be more adequate. Additionally, stents with a larger diameter might have a lower risk of migration. Materials and Methods The aim of this study was to evaluate the efficacy and complications associated with the use of colonic fully covered SEMS (FSEMS) in the treatment of postoperative leaks in critical patients. All patients with postoperative leaks of the upper gastrointestinal tract treated with colonic stents (Hanarostent® CCI) between 2010 and 2013 were retrospectively included. Results Four patients with postoperative leaks were treated with colonic SEMS. The underlying surgeries were a gastric bypass, an esophagogastrectomy for Boerhaave syndrome, a primary repair of esophagopleural fistula due to Boerhaave syndrome, and an esophagectomy due to esophageal cancer. The leaks were detected on average 17 days after the initial surgery. All patients needed admission to a critical care unit after index surgery. Stent placement was technically feasible in all patients. The median residence time of the stents was 7 weeks, and no complications were verified when they were removed. There were no cases of stent migration. The treatment was successful in all patients, with complete healing of the leaks. Discussion and Conclusions The placement of colonic FSEMS seems to be successful and safe in the treatment of postoperative leaks of the upper gastrointestinal tract.
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Affiliation(s)
- Paula Sousa
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - António Castanheira
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Diana Martins
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Juliana Pinho
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Ricardo Araújo
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Eugénia Cancela
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Paula Ministro
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Américo Silva
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
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Gonzalez JM, Servajean C, Aider B, Gasmi M, D'Journo XB, Leone M, Grimaud JC, Barthet M. Efficacy of the endoscopic management of postoperative fistulas of leakages after esophageal surgery for cancer: a retrospective series. Surg Endosc 2016; 30:4895-4903. [PMID: 26944730 DOI: 10.1007/s00464-016-4828-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Anastomotic leakages are severe and often lethal adverse events of surgery for esophageal cancer. The endoscopic treatment is growing up in such indications. The aim was to evaluate the efficacy and describe the strategy of the endoscopic management of anastomotic leakages/fistulas after esophageal oncologic surgery. METHODS Single-center retrospective study on 126 patients operated for esophageal carcinomas between 2010 and 2014. Thirty-five patients with postoperative fistulas/leakages (27 %) were endoscopically managed and included. The primary endpoint was the efficacy of the endoscopic treatment. The secondary endpoints were: delays between surgery, diagnosis, endoscopy and recovery; number of procedures; material used; and adverse events rate. Uni- and multivariate analyses were carried out to determine predictive factors of success. RESULTS There were mostly men, with a median age of 61.7 years ± 8.9 [43-85]. 48.6 % underwent Lewis-Santy surgery and 45.7 % Akiyama's. 71.4 % patients received neo-adjuvant chemo-radiation therapy. The primary and secondary efficacy was 48.6 and 68.6 %, respectively. The delay between surgery and endoscopy was 8.5 days [6.00-18.25]. Eighty-eight percentages of the patients were treated using double-type metallic stents, with removability and migration rates of 100 and 18 %, respectively. In the other cases, we used over-the-scope clips, naso-cystic drain or combined approach. The mean number of endoscopy was 2.6 ± 1.57 [1-10]. The mortality rate was 17 %, none being related to procedures. No predictive factor of efficacy could be identified. CONCLUSIONS The endoscopic management of leakages or fistulas after esophageal surgery reached an efficacy rate of 68.8 %, mostly using stents, without significant adverse events. The mortality rate could be decreased from 40-100 to 17 %.
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Affiliation(s)
- Jean-Michel Gonzalez
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France.
| | - C Servajean
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - B Aider
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - M Gasmi
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - X B D'Journo
- Department of Thoracic Surgery, APHM, North Hospital, University of Mediterranean, Marseille, France
| | - M Leone
- Intensive Care Unit, APHM, North Hospital, University of Mediterranean, Marseille, France
| | - J C Grimaud
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - M Barthet
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
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Weiner S, Heidsieck T, Chiappetta S, Stier C, Weiner RA. [Anastomosis and suture insufficiency after interventions for bariatric and metabolic surgery]. Chirurg 2015; 86:824-32. [PMID: 26296509 DOI: 10.1007/s00104-015-0071-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKROUND Metabolic surgery is internationally well-established for the treatment of obesity and its comorbidities. The numbers of procedures performed is steadily increasing. The results of surgery are superior in comparison to conservative treatment options regarding weight loss and resolution of comorbidities. The insufficiency of suture lines is a well-known and feared complication in the stapling procedures and is associated with an increased morbidity as well as mortality, especially in super obese patients. MATERIAL AND METHODS The current literature was reviewed and the results are reported within the context of own experience. RESULTS The most severe complications are staple line leakage after sleeve gastrectomy, leakage of anastomoses after bypass procedures and duodenal stump insufficiency. For the treatment of sleeve leakage various endoscopic procedures, such as over the scope (OTS) clips, stents and endoluminal vacuum therapy are available. Surgical revision, such as oversuturing, drainage and redo surgery are well-established. The management of all other complications is mainly by surgical intervention. Intraoperative standardization of procedures and knowledge of the physical foundations are essential for the prevention of leakage. Several preventive methods are available but randomized controlled trials are missing. CONCLUSION The therapy of leakages in the field of bariatric surgery is an interdisciplinary approach and dependent on the available resources in the treating hospital. The data reported show good results but the different reports published are inconsistent. Leakages often do not occur in the immediate postoperative period but in the sense of a long-term complication; therefore standardization of procedures and follow-up as well as complication management is mandatory. Randomized controlled studies must be promoted.
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Affiliation(s)
- S Weiner
- Adipositaszentrum, Chirurgische Klinik, Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488, Frankfurt am Main, Deutschland,
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