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Gibiino G, Binda C, Secco M, Giuffrida P, Coluccio C, Perini B, Fabbri S, Liverani E, Jung CFM, Fabbri C. Endoscopic Management of Bleeding in Altered Anatomy after Upper Gastrointestinal Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1941. [PMID: 38003990 PMCID: PMC10672978 DOI: 10.3390/medicina59111941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023]
Abstract
Postoperative non variceal upper gastrointestinal haemorrhage may occur early or late and affect a variable percentage of patients-up to about 2%. Most cases of intraluminal bleeding are an indication for urgent Esophagogastroduodenoscopy (EGD) and require endoscopic haemostatic treatment. In addition to the approach usually adopted in non-variceal upper haemorrhages, these cases may be burdened with difficulties in terms of anastomotic tissue, angled positions, and the risk of further complications. There is also extreme variability related to the type of surgery performed, in the context of oncological disease or bariatric surgery. At the same time, the world of haemostatic devices available in digestive endoscopy is increasing, meeting high efficacy rates and attempting to treat even the most complex cases. Our narrative review summarises the current evidence in terms of different approaches to endoscopic haemostasis in upper bleeding in altered anatomy after surgery, proposing an up-to-date guidance for endoscopic clinicians and at the same time, highlighting areas of future scientific research.
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Affiliation(s)
- Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Matteo Secco
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Paolo Giuffrida
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Barbara Perini
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, 35128 Padua, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Elisa Liverani
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
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Ryou SH, Bang KB. Endoscopic management of postoperative bleeding. Clin Endosc 2023; 56:706-715. [PMID: 37915192 PMCID: PMC10665615 DOI: 10.5946/ce.2023.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/30/2023] [Accepted: 06/12/2023] [Indexed: 11/03/2023] Open
Abstract
Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.
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Affiliation(s)
- Sung Hyeok Ryou
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Ki Bae Bang
- Department of Internal Medicine, H+ Yangji Hospital, Seoul, Korea
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Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14040980. [PMID: 35205730 PMCID: PMC8870330 DOI: 10.3390/cancers14040980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments. Abstract Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.
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Chu H, Kang B, Youn BY, Kim KI, Park J, Leem J. Comprehensive traditional East Asian medicine treatment strategy for obesity considering the therapeutic effects and adverse events: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2022; 101:e28673. [PMID: 35147089 PMCID: PMC8830816 DOI: 10.1097/md.0000000000028673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Obesity has become a serious global health problem due to its increasing prevalence. Because of several limitations or adverse events associated with conventional western medicine therapies, there has been an increase in demand for alternative therapies such as traditional East Asian medicine (TEAM). This study aims to provide comprehensive evidence-based information assessing the clinical efficacy and safety of TEAM treatment for obesity as the basis for reliable clinical strategies for patients with obesity. METHODS Electronic searches of the PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure, OASIS, and Korea Citation Index will be performed. Methodological quality will be assessed using the "risk of bias" tool. The primary outcome for efficacy will be weight loss. The secondary outcomes will be response rate, body mass index, waist circumference, and blood pressure. We will also evaluate the rates of adverse events and mortality for safety assessment. First, we will conduct a conventional pairwise meta-analysis. Next, we will conduct network meta-analysis using the frequentist approach. We shall verify the assumption of network meta-analysis and provide network geometry, P-score, net league table, and intervention-based forest plot. A subgroup analysis will be conducted to ascertain the factors that affect treatment, such as dosage, treatment duration, and severity of obesity. RESULTS The results of this study will provide high-quality systematic reviews that can assist decision making in obesity management. Our network meta-analysis results can provide direct and indirect comparison evidence on comparative efficacy and safety. CONCLUSION This study will provide fundamental data for prospective research on the application of TEAM in patients with obesity. PROTOCOL REGISTRY NUMBER OF ONLINE REGISTRY This study protocol was registered in open Science framework (OSF) (Registration DOI: 10.17605/OSF.IO/ETWDS). URL OF THE ONLINE REGISTRY https://osf.io/etwds.
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Affiliation(s)
- Hongmin Chu
- Daecheong Public Health Subcenter, 3, Daecheong-ro, Daecheong-myeon, Ongjin-gun, Incheon, Republic of Korea
| | - Byungsoo Kang
- College of Korean Medicine, Dongshin University, 67, Dongsindae-gil, Naju-si, Jeollanamdo, Republic of Korea
| | - Bo-Young Youn
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, 26, Kyungheedae-ro, Seoul, Republic of Korea
| | - Kwan-il Kim
- Division of Allergy, Immune Division of Allergy, Immune and Respiratory System, Department of Internal Medicine, College of Korean Medicine, Kyung Hee University, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, Republic of Korea
| | - Jinbong Park
- Department of Pharmacology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, Republic of Korea
| | - Jungtae Leem
- Research Center of Traditional Korean Medicine, Wonkwang University, 460, Iksan-daero, Sin-dong, Iksan, Jeollabuk-do, Republic of Korea
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Bang KB, Shin HD. Endoscopic treatment of surgery or procedure-related gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ki Bae Bang
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Hyun Deok Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
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Bowles-Cintron RJ, Perez-Ginnari A, Martinez JM. Endoscopic management of surgical complications. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Souto-Rodríguez R, Alvarez-Sánchez MV. Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results. World J Gastrointest Endosc 2017; 9:105-126. [PMID: 28360973 PMCID: PMC5355758 DOI: 10.4253/wjge.v9.i3.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/12/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.
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Campos JM, Moon R, Teixeira A, Ferraz AAB, Ferreria F, Kumbhari V. Endoscopic Management of Massive Hemorrhage 12 h Post Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2016; 25:1981-3. [PMID: 26231825 DOI: 10.1007/s11695-015-1812-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute (<24 h) staple line bleeding is not common but a known complication after bariatric surgery at a rate of 1-3%. In most cases, acute postoperative bleeding is mild and can be managed conservatively. Nonetheless, there are times when massive hemorrhage is encountered. Endoscopic treatment of these patients within 24 h of Roux-en-Y (RYGB) is controversial, due to fear of staple line dehiscence and/or perforation. Therefore, most surgeons prefer to undergo diagnostic laparoscopy for exploration and treatment. However, it has been reported that laparoscopic management of acute bleeding can be technically challenging with a high rate of morbidity as well as conversion to laparotomy. We herein present a multimedia video (6 min) demonstrating the management of acute massive hemorrhage after RYGB. METHODS A 46-year-old female with hemodynamic instability after massive hematemesis and melena underwent endoscopy. An overtube was utilized to allow removal of large blood clots which obstructed endoscopic visualization. Two bleeding points were noted, and these were successfully treated with adrenaline and endoscopic clips. RESULTS The patient rapidly improved during her hospital stay and commenced oral intake on day 1. A surveillance endoscopy was performed on day 5, and no stigmata of recent bleeding was noted. She was discharged home and is progressing well. CONCLUSIONS We suggest endoscopy is an appropriate first step for the investigation and management of acute intraluminal bleeding post bariatric surgery.
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Affiliation(s)
- Josemberg M Campos
- General and Digestive Surgery Unit, Pernambuco Federal University Hospital, 50610-160, Recife, Pernambuco, Brazil,
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da Rocha L, Ayub Pérez O, Arantes V. Endoscopic management of bariatric surgery complications: what the gastroenterologist should know. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Essential bariatric emergencies for the acute care surgeon. Eur J Trauma Emerg Surg 2015; 42:571-584. [PMID: 26669688 DOI: 10.1007/s00068-015-0621-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/07/2015] [Indexed: 12/19/2022]
Abstract
Bariatric surgery is the most effective treatment for morbid obesity. Due to the high volume of weight loss procedures worldwide, the general surgeon will undoubtedly encounter bariatric patients in his or her practice. Liberal use of CT scans, upper endoscopy and barium swallow in this patient population is recommended. Some bariatric complications, such as marginal ulceration and dyspepsia, can be effectively treated non-operatively (e.g., proton pump inhibitors, dietary modification). Failure of conservative management is usually an indication for referral to a bariatric surgery specialist for operative re-intervention. More serious complications, such as perforated marginal ulcer, leak, or bowel obstruction, may require immediate surgical intervention. A high index of suspicion must be maintained for these complications despite "negative" radiographic studies, and diagnostic laparoscopy performed when symptoms fail to improve. Laparoscopic-assisted gastric band complications are usually approached with band deflation and referral to a bariatric surgeon. However, if acute slippage that results in gastric strangulation is suspected, the band should be removed immediately. This manuscript provides a high-level overview of all essential bariatric complications that may be encountered by the acute care surgeon.
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Endoscopic management of bariatric surgery complications: what the gastroenterologist should know. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 81:35-47. [PMID: 26552500 DOI: 10.1016/j.rgmx.2015.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/16/2015] [Accepted: 06/18/2015] [Indexed: 12/11/2022]
Abstract
Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.
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Washino S, Hirai M, Kobayashi Y, Saito K, Miyagawa T. Heavy hematuria requiring cystectomy in a patient with hemophilia A: a case report and literature review. BMC Urol 2015; 15:84. [PMID: 26268821 PMCID: PMC4535382 DOI: 10.1186/s12894-015-0076-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/30/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hemophilia A is an X-linked recessive disorder caused by a deficiency in factor VIII. Hemophilia A affects 1 in 5,000-10,000 males. Hematuria is frequent in hemophilia. Hematuria in hemophilia is generally considered benign and manageable with conservative therapy; however, severe hematuria requiring surgical therapy has rarely been reported. CASE PRESENTATION A 60-year-old male with hemophilia A presented with persistent gross hematuria of unknown cause. He was treated with recombinant factor VIII products, followed by several conservative therapies as follows: clot evacuation by vesicoclysis, continuous bladder irrigation with normal saline, and intravesical instillation of aluminum hydroxide/magnesium hydroxide (Maalox); however, these failed to resolve the hemorrhaging. The patient was offered and consented to cystectomy with an ileal conduit. Intraoperative clotting was normal with the infusion of adequate recombinant factor VIII products and transfusion of fresh-frozen plasma, and the procedure was performed safely. After surgery, the patient had blood in his stool several times. No bleeding site was demonstrated in the colon by colonoscopy and (99m)Technetium-human serum albumin-diethylenetriaminepenta-acetic acid scintigraphy demonstrated that the extravasation of radioactive isotope was detected at the anal side of terminal ileum but not at the oral side. These findings were suspected to be bleeding from the ileoileal anastomosis. However, the bleeding was managed with recombinant factor VIII products. CONCLUSIONS Cystectomy in hemophilia may be safe, if monitored appropriately. Urinary diversion using the intestine may be avoided because anastomotic hemorrhage may become a problem.
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Affiliation(s)
- Satoshi Washino
- The Department of Urology, Saitama Medical Center Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama city, Saitama, Japan.
| | - Masaru Hirai
- The Department of Urology, Saitama Medical Center Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama city, Saitama, Japan. hirai-m-@omiya.jichi.ac.jp
| | - Yutaka Kobayashi
- The Department of Urology, Saitama Medical Center Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama city, Saitama, Japan.
| | - Kimitoshi Saito
- The Department of Urology, Saitama Medical Center Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama city, Saitama, Japan.
| | - Tomoaki Miyagawa
- The Department of Urology, Saitama Medical Center Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama city, Saitama, Japan.
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García-García ML, Martín-Lorenzo JG, Torralba-Martínez JA, Lirón-Ruiz R, Miguel Perelló J, Flores Pastor B, Pérez Cuadrado E, Aguayo Albasini JL. Emergency endoscopy for gastrointestinal bleeding after bariatric surgery. Therapeutic algorithm. Cir Esp 2014; 93:97-104. [PMID: 25438773 DOI: 10.1016/j.ciresp.2014.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/07/2014] [Accepted: 05/07/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm. PATIENTS AND METHOD From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy. RESULTS Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively. CONCLUSION Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.
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Affiliation(s)
- María Luisa García-García
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España.
| | - Juan Gervasio Martín-Lorenzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | | | - Ramón Lirón-Ruiz
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Joana Miguel Perelló
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Benito Flores Pastor
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Enrique Pérez Cuadrado
- Sección de Gastroenterología y Endoscopia, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - José Luis Aguayo Albasini
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España; Departamento de Cirugía, Campus de Excelencia Internacional «Campus Mare Nostrum», Universidad de Murcia, Murcia, España
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De Palma GD, Forestieri P. Role of endoscopy in the bariatric surgery of patients. World J Gastroenterol 2014; 20:7777-7784. [PMID: 24976715 PMCID: PMC4069306 DOI: 10.3748/wjg.v20.i24.7777] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/31/2013] [Accepted: 03/10/2014] [Indexed: 02/06/2023] Open
Abstract
Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett’s esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett’s esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.
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Chang PC, Huang CK, Malapan K. Transcatheter arterial vasopressin infusion for gastrojejunostomy hemorrhage after laparoscopic Roux-en-Y gastric bypass: a report of 3 cases. Surg Obes Relat Dis 2014; 10:e39-42. [PMID: 24529573 DOI: 10.1016/j.soard.2013.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 09/11/2013] [Accepted: 09/12/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Po-Chih Chang
- Division of General Surgery, Department of Surgery, E-DA Hospital/I-Shou University, Kaohsiung City, Taiwan; Bariatric and Metabolic International Surgery Center, E-DA Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - Chih-Kun Huang
- Division of General Surgery, Department of Surgery, E-DA Hospital/I-Shou University, Kaohsiung City, Taiwan; Bariatric and Metabolic International Surgery Center, E-DA Hospital/I-Shou University, Kaohsiung City, Taiwan.
| | - Kirubakaran Malapan
- Bariatric and Metabolic International Surgery Center, E-DA Hospital/I-Shou University, Kaohsiung City, Taiwan
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Hussain A, EL-Hasani S. Bariatric emergencies: current evidence and strategies of management. World J Emerg Surg 2013; 8:58. [PMID: 24373182 PMCID: PMC3923426 DOI: 10.1186/1749-7922-8-58] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 12/26/2013] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The demand for bariatric surgery is increasing and the postoperative complications are seen more frequently. The aim of this paper is to review the current outcomes of bariatric surgery emergencies and to formulate a pathway of safe management. METHODS The PubMed and Google search for English literatures relevant to emergencies of bariatric surgery was made, 6358 articles were found and 90 papers were selected based on relevance, power of the study, recent papers and laparoscopic workload. The pooled data was collected from these articles that were addressing the complications and emergency treatment of bariatric patients. 830,998 patients were included in this review. RESULTS Bariatric emergencies were increasingly seen in the Accident and Emergency departments, the serious outcomes were reported following complex operations like gastric bypass but also after gastric band and the causes were technical errors, suboptimal evaluation, failure of effective communication with bariatric teams who performed the initial operation, patients factors, and delay in the presentation. The mortality ranged from 0.14%-2.2% and increased for revisional surgery to 6.5% (p = 0.002). Inspite of this, mortality following bariatric surgery is still less than that of control group of obese patients (p = value 0.01). CONCLUSIONS Most mortality and catastrophic outcomes following bariatric surgery are preventable. The awareness of bariatric emergencies and its effective management are the gold standards for best outcomes. An algorithm is suggested and needs further evaluation.
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Affiliation(s)
- Abdulzahra Hussain
- Minimal access and bariatric unit, King’s College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, London BR6 8ND, UK
- Honorary Senior Lecturer at King’s College Medical School, London, UK
| | - Shamsi EL-Hasani
- Minimal access and bariatric unit, King’s College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, London BR6 8ND, UK
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Kumar N, Thompson CC. Endoscopic management of complications after gastrointestinal weight loss surgery. Clin Gastroenterol Hepatol 2013; 11:343-53. [PMID: 23142331 DOI: 10.1016/j.cgh.2012.10.043] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/23/2012] [Accepted: 10/26/2012] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Nitin Kumar
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies. Obes Surg 2011; 21:413-20. [PMID: 21240659 DOI: 10.1007/s11695-011-0354-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bleeding is a potentially serious complication after Roux-en-Y gastric bypass (RYGB). Preventive measures and therapeutic strategies have not been adequately defined. We reviewed data on 742 consecutive patients treated at the University of California San Francisco to identify cases of early and late bleeding (less or greater than 30 days after surgery) after RYGB. Bleeding was defined as symptoms or signs of bleeding, associated with blood transfusion. We recorded patient characteristics, details of the operative technique, diagnostic approach, therapeutic strategies, and outcomes. Twenty-six patients (3.5%) had postoperative bleeding, which mostly occurred in the first 30 days postoperatively (N=19). Hematocrit decreased significantly from preoperative values (-5.2 ± 3.1 without bleeding vs. -14.8 ± 4.7 with, p<0.01). Type 2 diabetes was more prevalent in patients who had bleeding (58% vs. 32%, p=0.03). No other patient characteristics or details of the operative technique were associated with different rates of bleeding. Therapeutic intervention other than transfusion was needed for seven patients with early bleeding (36.8%) and for all patients with late bleeding. Four patients with early bleeding required reoperation. Early bleeding source was intraluminal in four patients, intraperitoneal in five, and self-limited and of unknown location in ten. Late bleeding occurred on average at 62.6 months (range, 5 to 300 months) after index surgery, five patients required reoperation, and the source was always intraluminal. Bleeding after RYGB may be from various anatomic sites; details of the operative technique were not associated with different rates of bleeding, and therapy should be tailored to suspected location of bleeding.
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Ferreira LEVV, Song LMWK, Baron TH. Management of acute postoperative hemorrhage in the bariatric patient. Gastrointest Endosc Clin N Am 2011; 21:287-94. [PMID: 21569980 DOI: 10.1016/j.giec.2011.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is one of the treatment options for achieving and preserving weight loss and managing medical complications related to obesity. After bariatric surgery, early or late adverse events, such as intraluminal or extraluminal gastrointestinal hemorrhage, can occur. Early gastrointestinal bleeding is more often a complication associated with Roux-en-Y gastric bypass surgery than other bariatric procedures and usually arises from the gastrojejunal anastomosis. Early postoperative bleeding may be potentially life threatening, although death after postbariatric surgery as a consequence of acute bleeding is uncommon. Although early postoperative intraluminal bleeding can usually be managed conservatively, endoscopic therapy may be required.
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Affiliation(s)
- Lincoln E V V Ferreira
- Department of Medicine, Digestive Endoscopy Unit, Hospital Universitario da Universidade Federal de Juiz de Fora, Unidade de Endoscopia Digestiva-Avenida Eugenio do Nascimento s/no. Bairro: Dom Bosco - CEP:36038-330, Juiz de Fora, Minas Gerais, Brasil
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21
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Tanizawa Y, Bando E, Kawamura T, Tokunaga M, Ono H, Terashima M. Early postoperative anastomotic hemorrhage after gastrectomy for gastric cancer. Gastric Cancer 2010; 13:50-7. [PMID: 20373076 DOI: 10.1007/s10120-009-0535-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 12/02/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative anastomotic hemorrhage is a relatively rare complication, but it is lethal if not treated immediately. METHODS Of 1400 patients with gastric cancer who underwent gastrectomy between September 2002 and December 2007, postoperative anastomotic hemorrhage was observed in 6 patients. The surgical procedures, bleeding sites, methods of hemostasis, and clinical courses of these 6 patients were analyzed. RESULTS Of the 1400 patients, 878, 72, and 450 underwent distal, proximal, and total gastrectomy, respectively. The bleeding sites were as follows: transection line of the stomach using a linear stapler (n = 1); gastroduodenostomy using a circular stapler (n = 3); gastrojejunostomy by hand-suture (n = 1); and esophagojejunostomy using a circular stapler (n = 1). Five patients achieved complete hemostasis with endoscopic treatment. One patient underwent re-operation for anastomotic hemorrhage without endoscopic therapy. Two patients had delayed gastric emptying, and one patient developed an intraabdominal abscess after hemostatic treatment. CONCLUSION Postoperative anastomotic hemorrhage is an infrequent but potentially life-threatening complication. Endoscopy appears to be useful for both the confirmation of bleeding and therapeutic intervention.
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Affiliation(s)
- Yutaka Tanizawa
- Division of Gastric Surgery, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
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Tang SJ, Olukoga CO, Provost DA, Hogg D, Livingston E, Scott DJ. Gastrojejunal stomal reduction with the T-tag device in porcine models (with videos). Gastrointest Endosc 2008; 68:132-8. [PMID: 18577481 DOI: 10.1016/j.gie.2008.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 02/04/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Gastrojejunal (GJ) stomal dilatation associated with weight regain is a late complication. Surgical revision is usually required for stomal or pouch reduction. OBJECTIVE Our purpose was to evaluate the technical feasibility, efficacy, and safety of stomal reduction with endoscopic T-tag devices. DESIGN Prospective nonsurvival studies were conducted in pigs (n = 2, 110 pounds each). INTERVENTIONS Three GJ stomas were created in each pig through a midline laparotomy by using circular staplers. Endoscopic GJ stomal reduction/revision was performed on these newly created stomas with an Olympus T-tag device. Necropsy was performed to examine the deployed T-tag locations and procedure-related adjacent tissue/organ injury and to assess the effectiveness of stomal reduction. RESULTS Endoscopic stomal revision was performed on 5 stomas with moderate stomal reduction. One GJ stoma could not be accessed easily by endoscopy because of the small size of the gastric pouch. An average of 4 T-tag devices was deployed around each stoma. The procedural time was about 61 +/- 12 minutes for each stomal reduction. Overall, 26 of 39 (66.7%) T-bars were deployed in accepted locations. The stomas were reduced from 1.60 +/- 0.21 mm x 1.44 +/- 0.14 mm to 1.28 +/- 0.29 mm x 0.98 +/- 0.17 mm and the percentage of stomal reduction was 27.3% +/- 13.3%. In the end, a therapeutic gastroscope could not be advanced through the reduced stomas. In 2 stomas, 5 of 39 (12.8%) T-bars injured or attached to the adjacent organs: isolated stomach and abdominal wall. LIMITATION Nonsurvival pig studies. CONCLUSIONS Endoscopic stomal reduction with T-tag device is technically feasible and effective in two thirds of trials. However, it is associated with a small risk of adjacent organ/tissue injury with the current prototype device and deployment method.
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Affiliation(s)
- Shou-Jiang Tang
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9151, USA
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Retrograde endoscopic cystgastrostomy for pancreatic pseudocyst drainage after a Prior Roux-en-Y gastric bypass. Obes Surg 2008; 19:243-246. [PMID: 18581190 DOI: 10.1007/s11695-008-9611-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 06/02/2008] [Indexed: 10/21/2022]
Abstract
A 47-year-old woman with a history of Roux-en-Y gastric bypass developed a pancreatic pseudocyst after an episode of acute necrotizing pancreatitis. She presented with intractable abdominal pain and weight loss. Computed tomography scan revealed an enlarging pancreatic fluid collection abutting the gastric antrum. The patient underwent exploratory laparotomy, at which a Whipple procedure was aborted due to severe fibrosis and necrosis of her pancreas. Retrograde peroral endoscopic pancreatic pseudocyst drainage was successfully performed through the defunctionalized stomach.
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Tang SJ, Tang L, Jazrawi SF, Provost DA. Endotherapy in Unusual Bariatric Surgical Complications (with Videos). Obes Surg 2008; 18:423-8. [DOI: 10.1007/s11695-008-9448-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2007] [Accepted: 01/22/2008] [Indexed: 11/28/2022]
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