Endoscopic Management of Massive Hemorrhage 12 h Post Laparoscopic Roux-en-Y Gastric Bypass

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

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.

AGA Clinical Practice Update on Evaluation and Management of Early Complications After Bariatric/Metabolic Surgery: Expert Review

DESCRIPTION

Endoscopic techniques are paramount in the identification and management of complications after surgery, though collaboration with other specialties is obligatory. Unfortunately, the evaluation and treatment algorithms are not standardized and there is a paucity of high-quality prospective studies to provide clarity regarding the best approach. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery.

METHODS

The best practice advice outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. BEST PRACTICE ADVICE 1: Clinicians performing endoscopic approaches to treat early major postoperative complications should do so in a multidisciplinary manner with interventional radiology and bariatric/metabolic surgery co-managing the patient. Daily communication is advised. BEST PRACTICE ADVICE 2: Clinicians embarking on incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a comprehensive knowledge of the indications, contraindications, risks, benefits, and outcomes of each of the endoscopic treatment techniques. They should also have knowledge of the risks and benefits of alternative methods such as surgical and interventional radiological based approaches. BEST PRACTICE ADVICE 3: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have expertise in interventional endoscopy techniques, including but not limited to: using concomitant fluoroscopy, stent deployment and retrieval, managing stenosis, and managing percutaneous drains. BEST PRACTICE ADVICE 4: Clinicians should screen all patients undergoing endoscopic management of bariatric/metabolic surgical complications and dietary intolerance for comorbid medical (nutrient deficiencies, infection, pulmonary embolism) and psychological (depression, anxiety) conditions. BEST PRACTICE ADVICE 5: Endoscopic approaches to managing complications of bariatric/metabolic surgery may be considered for patients in the immediate, early and late postoperative periods depending on hemodynamic stability. BEST PRACTICE ADVICE 6: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a detailed understanding of the pathophysiologic mechanisms initiating and perpetuating conditions such as staple-line leaks. This will allow for a prompt diagnosis and appropriate therapy to be targeted not only at the area of interest, but also any concomitant downstream stenosis. BEST PRACTICE ADVICE 7: Clinicians should recognize that the goal for endoscopic management of staple-line leaks are often not necessarily initial closure of the leak site, but rather techniques to promote drainage of material from the perigastric collection into the gastric lumen such that the leak site closes by secondary intention.

Endoscopic Suturing for Massively Bleeding Marginal Ulcer 10 days Post Roux-en-Y Gastric Bypass

BACKGROUND

Marginal ulceration post Roux-en-Y gastric bypass (RYGB) with associated bleeding, although infrequently encountered, can be challenging to treat. Flexible endoscopic therapy is preferred over surgery due to its minimally invasive nature. Bleeding ulcers have traditionally been treated endoscopically by injecting epinephrine, bipolar hemostasis, or clips. Here, we describe our treatment with endoscopic suturing for a massively bleeding marginal ulcer after RYGB.

METHODS

A 56-year-old female 10 days post RYGB underwent her fourth endoscopy for investigation and management of hematemesis and was found to have a large bleeding anastomotic ulcer. A Rothnet was utilized to remove large blood clots which obstructed endoscopic visualization. Two marginal ulcers were noted, and these were successfully oversewn with endoscopic suturing. The multimedia video (7 min) demonstrates the management of massively bleeding marginal ulcer after RYGB by endoscopic suturing.

RESULTS

Patient had no further bleeding and tolerated diet the subsequent day. She was discharged home with no further episodes of hematemesis, and follow-up at 6 weeks showed well-healed ulcer on endoscopy.

CONCLUSION

Endoscopic suturing of a bleeding marginal ulcer appears technically feasible and safe. It should be considered in the treatment algorithm prior to emergency surgery.