Percutaneous Image-Guided Abdominal Interventions for Leaks and Fistulas Following Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Is the Surgical Drainage Mandatory for Leak after Sleeve Gastrectomy?

INTRODUCTION

Despite the unanimous acknowledgement of the laparoscopic sleeve gastrectomy (LSG) worldwide, the leak remains its deficiency. For the last decade, the surgical treatment was practically considered mandatory for almost any collection following LSG. The aim of this study is to evaluate the need for surgical drainage for leak following LSG.

METHODS

All consecutive patients having gone through LSG from January 2017 to December 2020 were enrolled in our study. Once the demographic data and the leak history were registered, we analyzed the outcome of the surgical or endoscopic drainage, the characteristics of the endoscopic treatment, and the evolution to complete healing.

RESULTS

A total of 1249 patients underwent LSG and the leak occurred in 11 cases (0.9%). There were 10 women with a mean age of 47.8 years (27-63). The surgical drainage was performed for three patients and the rest of the eight patients underwent primary endoscopic treatment. The endoscopic treatment was represented with pigtails for seven cases and septotomy with balloon dilation for four cases. In two out of these four cases, the septotomy was anticipated by the use of a nasocavitary drain for 2 weeks. The average number of endoscopic procedures was 3.2 (range 2-6). The leaks achieved complete healing after an average duration of 4.8 months (range 1-9 months). No mortality was recorded for a leak.

CONCLUSIONS

The treatment of the gastric leak must be tailored to each patient. Although there is still no consensus for the endoscopic drainage of leaks after LSG, the surgical approach can be avoided in up to 72%. The benefits of pigtails and nasocavitary drains followed by endoscopic septotomy are undeniable, and they should be included in the armamentarium of any bariatric center.

Swallowable Intragastric Balloon: First Consecutive Experience in Argentina

Background: Swallowable balloons are innovative devices for the treatment of obesity. Endoscopy or anesthesia for implantation is not required. They are generally well tolerated and experience reports satisfactory results in relation to weight loss. The objective of this study was to analyze the first experience with the implementation of a swallowable balloon in Argentina. Methods: It is a descriptive retrospective observational study on the treatment of obesity in patients who underwent swallowable balloons in Argentina, admitted to one center, in a period time of 12 months with a follow-up of 6 months. Results: A total of n = 153 patients were recruited between June 2021 and May 2022, 78% were women and 22% men. The average age was 39 years. Average body mass index was 29.5 kg/m². Balloon implantation was performed with complete swallowing by the patients in 19.4% of the cases, swallowing with operator assistance in 55.5%, and swallowing with stylet assistance in 25%. The adverse effects reported were abdominal pain (80%), nausea (60%), vomiting (38%), headache (36%), gastroesophageal reflux (29%), constipation (11%), and diarrhea (7%). No deaths were reported. A mean 4-month weight loss of 12% was reported. Conclusion: Swallowable balloon for the treatment of obesity is effective, safe, and well tolerated. Adverse effects are not severe.

Chronic Gastric Dilation-Surgical Management

Background: Chronic dilation of the gastric remnant is a rare complication, although it can be serious. It is due to an exaggerated distension of the gastric remnant after a Roux-en-Y gastric bypass (RYGB). Clinical suspicion and computed tomography (CT) are essential for its diagnosis. Its treatment is by means of a decompressive gastrostomy, which can be percutaneous or surgical, an option that can be carried out in certain patients. We present a clinical case of chronic dilation of the gastric remnant and its laparoscopic surgical resolution. Methods: We present a clinical case of a 67-year-old patient who underwent a RYGB. An abdominal CT scan showed chronic dilation of the gastric remnant. A laparoscopic biopsy and a laparoscopic-assisted percutaneous gastrostomy were performed. Conslusion: The combined percutaneous laparoscopic approach is a good option for cases of chronic gastric dilations of unknown origin, allowing to discover and treat its causes.

Reflux After Sleeve Gastrectomy: An Update

Background: Modifications of gastric anatomy, function, and of the esophagogastric junction secondary to sleeve gastrectomy (SG) can worsen the symptoms of gastroesophageal reflux disease (GERD). Its late diagnosis and poor treatment can lead to serious complications. In recent years, attempts have been made to optimize preoperative studies and improve surgical techniques to prevent this problem. The aim of this study was to update on the presence of GERD and their symptoms post-SG. Methods: A literature review of articles based on randomized clinical trials on the presence of GERD after SG was carried out, in a period of 10 years. Results: A result of 336 articles was obtained, of which 327 were discarded and 9 were included. The variables of GERD post-SG were analyzed according to their symptoms ("improved," "worsened," and "unchanged"), "remission," or appearance "de novo." Conclusion: GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG, and has been diagnosed de novo. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence.

Role of Primary Use of Mega Stents Alone and Combined with Other Endoscopic Procedures for Early Leak and Stenosis After Bariatric Surgery, Single-Institution Experience

PURPOSE

Surgical therapy for post-bariatric surgery complications is associated with significant morbidity and mortality. Endoscopic options like primarily endoscopically placed fully covered self-expandable metallic stents (SEMS) offer significant benefits for the management of leaks and obstructions or stenosis, and even in case of mega stent failure, further endoscopic techniques could resolve the situation.

MATERIALS AND METHODS

We conducted a single-centre retrospective study on patients with leakage and stenosis/obstruction after bariatric surgery who were managed primarily by SEMS between January 2015 and January 2019. Clinical success rate was evaluated in terms of the cure of the reason for stenting, the need for other interventions, and the presentation of stent-related complications.

RESULTS

There were 58 patients included, (50 with leak, 8 with stenosis/obstruction following bariatric surgery). Mean time to stent placement was 6.82 (±1.64) days for the leak group and 35 (±21.13) days for the stenosis group (p = 0.019). Successful outcomes with SEMS alone were achieved in 42 (72.41%) patients, while 16 patients had failed SEMS treatment, of whom 14 were successfully managed by endoscopic procedures while two cases needed surgical intervention. Of the SEMS-related complications encountered, 25.86% were ulcers; 24.13%, vomiting; 22.41%, gastroesophageal reflux disease (GerdQ≥8); 18.96%, stent migration; and 5.17%, stent intolerance.

CONCLUSION

A mega stent is an effective and safe tool for the early management of post-bariatric surgery leakage and stenosis, and it is associated with acceptable rates of failure that can be managed by further endoscopic techniques in most of the patients.

Image-Guided Surgery for Common Bile Duct Stones After Roux-en-Y Gastric Bypass

Background: The relationship between obesity with common bile duct stone (CBDS) is close and increases after a Roux-en-Y gastric bypass (RYGB). Due to the anatomical modification, direct endoscopic access is not always possible. For this reason, image-guided surgery (IGS) by percutaneous transhepatic biliary drainage (PTBD) of the common bile duct (CBD) could be a first-line approach for the treatment of post-RYGB choledocholithiasis. The aim of this study was to analyze the feasibility and safety of CBDS treatment after RYGB with IGS. Materials and Methods: We present a descriptive retrospective observational multicentric study on the treatment of choledocholithiasis in patients operated on for RYGB using IGS through a minimally invasive approach by PTBD. The diagnosis of CBDS was made according to the symptoms of the patients, supported by blood tests, and medical images. Treatment was planned in two stages: in the first step, a PTBD was performed, and in the second step the choledocholithiasis was removed. Results: Of a total of 1403 post-RYGB patients, 21 presented choledocholithiasis. Of these, n = 18 were included. Symptoms were reported in n = 15 (8 cholestatic jaundice, 7 cholangitis), whereas n = 3 were asymptomatic. Percutaneous treatment was performed in all these patients, treated with a balloon and stone basket. A hyperamylasemia without pancreatitis was observed in 3 patients. No complications or deaths associated with the procedure were reported. The average hospital stay was 8.6 days. Conclusion: IGS is an interesting option for the treatment CBDS after RYGB. For these patients, PTBD is feasible and safe.

What is the Role of Image-Guided Endovascular Surgery in Postbariatric Surgery Bleeding Complications?

Background: Obesity treatment requires surgical procedures included in bariatric surgery. Bleeding complications are reported in 1%-4%. Image-guided surgery (IGS) includes minimally invasive procedures that have the advantage of less aggression to the patient, fewer complications, and a quick recovery. Endovascular therapy by interventional radiology (IR) is a minimally invasive image-guided procedure widely used in central, peripheral, and splanchnic vascular pathology. Treatment of postoperative bleeding in bariatric surgery can be aided by image-guided endovascular procedures. Objectives: The aim of this study is to carry out an update on the application of IR in bariatric surgery bleeding complications. Bleeding Complications: General rate of postoperative complications in bariatric surgery is 0%-10%. Postoperative bleeding (1%-4%) can be gastrointestinal (endoscopic treatment) or intra-abdominal (surgical treatment/relaparoscopy). In the case of arterial vascular lesions that cannot be resolved either endoscopically or surgically, the option of endovascular treatment with IR should be considered. Conclusions: Endovascular approach through IR and IGS in bleeding complications after bariatric surgery is presented as a valid minimally invasive therapy option in this group of patients.