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Ferrer-Márquez M, García-Redondo M, Maturana-Ibáñez V, Estébanez-Ferrero B, Fernández-Alonso A, Rubio-Gil F, Zamora Soler JA, Ferrer-Ayza M. Bile reflux and marginal ulcers after one-anastomosis gastric bypass (OAGB). A narrative review. Cir Esp 2023; 101 Suppl 4:S69-S75. [PMID: 37085133 DOI: 10.1016/j.cireng.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/24/2022] [Accepted: 12/11/2022] [Indexed: 04/23/2023]
Abstract
One-anastomosis gastric bypass has now become the third most commonly performed bariatric technique worldwide. However, as a consequence of the configuration of this surgery, it can present some chronic complications (anastomotic mouth ulcers and biliary reflux) that physicians must come to better understand and assess. In this narrative review, we aimed to update our knowledge of both the diagnosis and treatment of these two complications in the context of bariatric surgeries. We concluded that a series of pre-, intra-, and postoperative preventive strategies should be considered by surgeons to help reduce the appearance of these complications.
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Affiliation(s)
- Manuel Ferrer-Márquez
- Departamento de Cirugía Bariátrica, Hospital Universitario Torrecárdenas, Almería, Spain; Departamento de Cirugía Bariátrica (Obesidad Almería), Hospital Mediterráneo, Almería, Spain.
| | - Manuel García-Redondo
- Departamento de Cirugía Bariátrica, Hospital Universitario Torrecárdenas, Almería, Spain.
| | | | | | - Ana Fernández-Alonso
- Departamento de Obstetricia y Ginecología, Hospital Universitario Torrecárdenas, Almería, Spain.
| | - Francisco Rubio-Gil
- Departamento de Cirugía Bariátrica (Obesidad Almería), Hospital Mediterráneo, Almería, Spain.
| | - José A Zamora Soler
- Clinical Nursing Research Group, Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Alicante, Alicante, Spain.
| | - Manuel Ferrer-Ayza
- Departamento de Cirugía Bariátrica (Obesidad Almería), Hospital Mediterráneo, Almería, Spain.
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2
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Kolyadko PV, Kolyadko VP, Degovtsov EN, Samoilov VS, Stepanenko AV. [Non-surgical treatment of staple-line suture leakage after redo sleeve gastrectomy]. Khirurgiia (Mosk) 2023:83-89. [PMID: 36800874 DOI: 10.17116/hirurgia202303183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Redo bariatric procedures are common. However, redo sleeve gastrectomy is not a frequent case of repeated bariatric surgery and can be performed rather as a necessary measure in difficult intraoperative conditions. We report a patient who underwent laparoscopic adjustable gastric band placement, its blockage and surgical removal, sleeve gastrectomy and redo sleeve gastrectomy. After that, staple-line suture failure developed that required endoscopic clipping.
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Affiliation(s)
- P V Kolyadko
- Nizhnevartovsk District Clinical Hospital, Nizhnevartovsk, Russia
| | - V P Kolyadko
- Nizhnevartovsk District Clinical Hospital, Nizhnevartovsk, Russia
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3
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Ahn JY. Endoscopic management of postoperative upper gastrointestinal leakage. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ji Yong Ahn
- Departments of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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4
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McCarty TR, Kumar N. Revision Bariatric Procedures and Management of Complications from Bariatric Surgery. Dig Dis Sci 2022; 67:1688-1701. [PMID: 35347535 DOI: 10.1007/s10620-022-07397-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
Abstract
Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Nitin Kumar
- HSHS Medical Group, Springfield, IL, 62704, USA.
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5
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Bhurwal A, Mutneja H, Tawadross A, Pioppo L, Brahmbhatt B. Gastrointestinal fistula endoscopic closure techniques. Ann Gastroenterol 2020; 33:554-562. [PMID: 33162732 PMCID: PMC7599355 DOI: 10.20524/aog.2020.0543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022] Open
Abstract
With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.
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Affiliation(s)
- Abhishek Bhurwal
- Department of Gastroenterology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ (Abhishek Bhurwal, Augustine Tawadross, Lauren Pioppo)
| | - Hemant Mutneja
- Department of Gastroenterology, John H Stroger Cook County Hospital, Chicago, Illinois (Hemant Mutneja)
| | - Augustine Tawadross
- Department of Gastroenterology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ (Abhishek Bhurwal, Augustine Tawadross, Lauren Pioppo)
| | - Lauren Pioppo
- Department of Gastroenterology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ (Abhishek Bhurwal, Augustine Tawadross, Lauren Pioppo)
| | - Bhaumik Brahmbhatt
- Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida (Bhaumik Brahmbhatt), USA
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6
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Iannelli A, Treacy P, Sebastianelli L, Schiavo L, Martini F. Perioperative complications of sleeve gastrectomy: Review of the literature. J Minim Access Surg 2019; 15:1-7. [PMID: 29737316 PMCID: PMC6293679 DOI: 10.4103/jmas.jmas_271_17] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sleeve gastrectomy (SG) has known a spectacular rise worldwide during the last decade. The absence of digestive anastomosis simplifies the surgical technique, reducing anastomosis-related complications such as fistula, stricture and marginal ulcer. Furthermore, the respect for digestive continuity preserves the functions of pylorus, that regulates gastric emptying, and duodenum, where calcium, B vitamins and iron are absorbed. Despite the multiple advantages, SG also has specific complications such as bleeding, stenosis, portal thrombosis and leak. The staple line leak at the oesophagogastric junction is the most feared complication and its prevention remains difficult, as the involved mechanisms have been only partially elucidated. Its management is long and requires a multidisciplinary technical platform including Intensive Care Unit, digestive endoscopy and interventional radiology as well as a specialised surgeon. The aim of this review is to explain in detail the perioperative complications of SG, their prevention and treatment, referring to the most recent available literature.
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Affiliation(s)
- Antonio Iannelli
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice; Inserm, U1065, Team 8 "Hepatic Complications of Obesity"; University of Nice Sophia Antipolis, Nice, France
| | - Patrick Treacy
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Lionel Sebastianelli
- Digestive Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Luigi Schiavo
- Department of Cardio-Thoracic and Respiratory Science, University of Campania "Luigi Vanvitelli"; IX Division of General Surgery, Vascular Surgery and Applied Biotechnology, Naples University Polyclinic, Naples, Italy
| | - Francesco Martini
- Digestive and Bariatric Surgery Unit, Joseph Ducuing Hospital, Toulouse, France
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7
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Clinical Feasibility and Safety of Endoscopic Self-Expandable Metal Stent Placement for Upper Gastrointestinal Pathologies. Int Surg 2018. [DOI: 10.9738/intsurg-d-15-00169.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We aimed to review our experiences to evaluate the practicality, safety, and effectiveness of endoscopic stent placement for the palliation of malignant obstructions of the upper gastrointestinal system (GIS) and the treatment of postoperative complications such as failure of anastomoses and fistulae. Endoscopic stent placement is increasingly used in the upper GIS for the management of both high grade malignancies causing obstruction and benign pathologies such as anastomosis failures, gastrointestinal fistulae, and strictures. Hospital records, clinical data, and endoscopy reports of 61 patients who had undergone endoscopic stenting between the years 2012 and 2015 were analyzed retrospectively. For all patients, self-expandable metal covered stents were used. Data involving technical and clinical success rates, complication, morbidity, and mortality rates of the endoscopic stenting procedure was collected and simple statistical analyses were made. Endoscopic stenting was successful in 60 of 61 patients (98.3%). Overall technical success rate was found to be 98.3%; clinical success rate, 86.6%; complication rate, 4.9%. No stent related mortality was observed in our series. Endoscopic stents can be effectively and safely used in the treatment of various lesions of the upper GIS.
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8
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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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9
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Hancock J, Jackson S, Johnson AB. The Long-Term Psychological Impact of Disclosing (Or Not) Laparoscopic Adjustable Gastric Banding Surgery. Bariatr Surg Pract Patient Care 2018. [DOI: 10.1089/bari.2017.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jude Hancock
- Department of Diabetes and Endocrinology, Southmead Hospital, Bristol, United Kingdom
| | - Sue Jackson
- Department of Psychology, University of the West of England, Bristol, United Kingdom
| | - Andrew B. Johnson
- Department of Diabetes & Endocrinology, Southmead Hospital, Bristol, United Kingdom
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10
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Bemelman WA, Baron TH. Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae. Gastroenterology 2018; 154:1938-1946.e1. [PMID: 29454791 DOI: 10.1053/j.gastro.2018.01.067] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/05/2018] [Accepted: 01/06/2018] [Indexed: 02/06/2023]
Abstract
Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.
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Affiliation(s)
- Willem A Bemelman
- Department of Surgery, The Academic Medical Center and University of Amsterdam, Amsterdam, The Netherlands
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill North Carolina. todd_baron.@med.unc.edu
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11
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Endoscopic Suturing for Massively Bleeding Marginal Ulcer 10 days Post Roux-en-Y Gastric Bypass. Obes Surg 2017; 27:1394-1396. [PMID: 28247322 DOI: 10.1007/s11695-017-2621-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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12
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Almadi MA, Bamihriz F, Alharbi O, Azzam N, Aljammaz A, Eltayeb M, Thaniah S, Aldohayan A, Aljebreen A. Use of Self-Expandable Metal Stents in the Treatment of Leaks Complicating Laparoscopic Sleeve Gastrectomy: A Cohort Study. Obes Surg 2017; 28:1562-1570. [DOI: 10.1007/s11695-017-3054-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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13
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Périssé LGS, Périssé PCM, Bernardo Júnior C. Endoscopic treatment of the fistulas after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Rev Col Bras Cir 2017; 42:159-64. [PMID: 26291256 DOI: 10.1590/0100-69912015003006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 09/10/2014] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE to evaluate the use of endoscopic self-expandable metallic prostheses in the treatment of fistulas from sleeve gastrectomy and Roux en y gastric bypass. METHODS all patients were treated with fully coated auto-expandable metallic prostheses and were submitted to laparoscopic or CT-guided drainage, except for those with intracavitary drains. After 6-8 weeks the prosthesis was removed and if the fistula was still open a new prostheses were positioned and kept for the same period. RESULTS the endoscopic treatment was successful in 25 (86.21%) patients. The main complication was the migration of the prosthesis in seven patients. Other complications included prosthesis intolerance, gastrointestinal bleeding and adhesions. The treatment failed in four patients (13.7%) one of which died (3.4%). CONCLUSION endoscopic treatment with fully coated self-expandable prosthesis was effective in treating most patients with fistula after sleeve gastrectomy and roux en y gastric bypass.
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Affiliation(s)
| | | | - Celso Bernardo Júnior
- Hospital Universitário Gaffrée e Guinle, Universidade Federal do Estado do Rio de Janeiro, RJ, BR
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14
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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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15
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Lee S, Ahn JY, Na S, Na HK, Jung KW, Kim DH, Lee JH, Choi KD, Song HJ, Lee GH, Jung HY, Kim SO. Clinical features of postoperative anastomotic bleeding after gastrectomy and efficacy of endoscopic hemostasis: a case-control study. Surg Endosc 2016; 31:3210-3218. [PMID: 27864714 DOI: 10.1007/s00464-016-5347-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/09/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Postoperative anastomotic bleeding (PAB) is relatively rare; however, it can be lethal if not treated immediately. The aim of our study was to investigate the clinical features of PAB and the efficacy of endoscopic hemostasis (EH) for PAB. METHODS Between January 2004 and May 2013, 16,591 patients underwent gastrectomy for gastric cancer at Asan Medical Center. Among them, 36 patients who experienced PAB within 2 months after the gastrectomy were enrolled as a case group. Each subject was matched at a ratio of 1:5 with randomly selected patients without bleeding during the same period (n = 180, control group). The clinical outcomes and risk factors for patients with PAB were compared with those of the control group, and the results of EH were evaluated retrospectively. RESULTS The incidence of PAB was 0.22% (n = 36), and the median duration from gastrectomy to PAB was 34.5 h (interquartile range, 12.3-132.8 h). EH was attempted in 25 patients (69.4%); surgery was performed in 6 patients (16.7%); and conservative management was applied in 5 patients (13.9%). PAB-related death occurred in three patients (8.3%; one in each treatment modality). Among 25 patients with primary EH, 16 were treated successfully (64%) and hemoclip was the most commonly used endoscopic tool (52%). In the multivariate analysis, the type of gastrectomy was found to be a risk factor for PAB (odds ratio 3.448, 95% confidence interval, 1.138-10.448, p = .029). CONCLUSIONS Although PAB is an infrequent and potentially life-threatening complication, endoscopy can be considered as a useful method to avoid additional surgery in properly selected patients.
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Affiliation(s)
- Sunpyo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Shin Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Abstract
This article reviews the data for diagnostic and uncomplicated therapeutic upper endoscopy, which show it is safe and effective to perform the procedure under moderate sedation with a combination of benzodiazepine and opioids. For more complex procedures or for superobese patients anesthesia support is recommended. Performing endoscopy in this population should alert providers to plan carefully and individualize sedation plans because there is no objective way to quantify this risk pre-endoscopically.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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17
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Malli CP, Sioulas AD, Emmanouil T, Dimitriadis GD, Triantafyllou K. Endoscopy after bariatric surgery. Ann Gastroenterol 2016; 29:249-57. [PMID: 27366025 PMCID: PMC4923810 DOI: 10.20524/aog.2016.0034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/08/2016] [Indexed: 12/16/2022] Open
Abstract
Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.
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Affiliation(s)
- Chrysoula P. Malli
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Athanasios D. Sioulas
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Theodoros Emmanouil
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - George D. Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
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19
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Effectiveness of Endoscopic Management Using Self-Expandable Metal Stents in a Large Cohort of Patients with Post-bariatric Leaks. Obes Surg 2016; 25:1569-76. [PMID: 25676154 DOI: 10.1007/s11695-015-1596-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic management of post-bariatric surgery leaks using self-expandable metal stents (SEMSs) is an alternative to revisional surgery. We evaluated the effectiveness of a standardized protocol for management of post-bariatric surgery leaks in a large cohort of patients. METHODS Data from patients with anastomotic leaks after bariatric surgery endoscopically treated with partially covered SEMS in our institution between January 2006 and December 2012 were retrospectively reviewed. Patients were divided into four categories: (1) healing of fistula after only one SEMS, (2) healing of fistula after multiple SEMSs and/or additional therapy, (3) healing of fistula after salvage endoscopic procedure despite SEMS failure, and (4) SEMS and endoscopic failure for fistula healing. RESULTS Ninety-one patients (median age 42 years; 33 males) were considered suitable for inclusion. Our standardized stenting policy was successful in 74 patients (81 %). Among the 17 patients with SEMS failure, 6 patients were ultimately healed by internal drainage of the leakage (7 %). Endoscopic treatment failed in 11 patients (12 %). In univariate analysis, male gender (p = 0.024), higher prebariatric surgery BMI (p = 0.025), and shorter delay between surgery and SEMS placement (p = 0.011) were more frequently observed in the one-step treatment group (group 1) as compared to the other groups. In multivariate analysis, gender (p = 0.035) and delay between surgery and SEMS placement (p = 0.042) were independent predictive factors of endoscopic success. CONCLUSIONS Endoscopic management using SEMS for anastomotic leaks after bariatric surgery is effective and may avoid risky surgical reintervention in 81 % of patients. Early stenting was a major significant factor associated with increased success.
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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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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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Abstract
PURPOSE OF REVIEW Bariatric surgery is recognized as the most effective treatment against obesity as it results in significant weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. This review illustrates the latest developments in the endoscopic management of bariatric surgical complications. RECENT FINDINGS For successful management of complications, precipitating and perpetuating factors must be addressed in addition to directing therapy at the target pathology. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Chronic proximal staple-line leaks/fistulas frequently do not respond to primary closure with diversion therapy, and a new technique of stricturotomy has been reported to improve outcomes. Innovations in the field of transoral endoscopic instruments have led to the development of a single-session entirely internal endoscopic retrograde cholangiopancreatography by creating a gastrogastric anastomosis. SUMMARY Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention. Computed tomography-guided drainage may be necessary in patients with drainable fluid collections. VIDEO ABSTRACT http://links.lww.com/COG/A11.
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Patients With Roux-en-Y Gastric Bypass Require Increased Sedation During Upper Endoscopy. Clin Gastroenterol Hepatol 2015; 13:1432-6. [PMID: 25769410 DOI: 10.1016/j.cgh.2015.02.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 01/22/2015] [Accepted: 02/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS After Roux-en-Y gastric bypass (RYGB), many patients experience changes in metabolism that could affect the amount of sedative they require. We assessed whether patients who have vs have not received RYGB have different sedation requirements during esophagogastroduodenoscopy (EGD). METHODS In a retrospective study, we collected data from patients who had received RYGB (n = 200; mean age, 45 years; 188 women; body mass index [BMI], 34.0 ± 7.1 kg/m2) or had not (controls, n = 200; mean age, 45 years; 188 women; BMI, 34.1 ± 7.2 kg/m2) and underwent EGD under conscious sedation from 2005 through 2010; groups were matched for age, sex, and BMI. Sedative doses were compared by using the Student t test. Multivariate linear regression was used to identify factors associated with sedation dose. We performed a subgroup analysis of RYGB patients who underwent EGD before and after RYGB, comparing sedative doses with a paired t test. RESULTS Patients with RYGB were given 132.4 ± 40.4 μg fentanyl and 5.4 ± 1.5 mg midazolam, whereas controls received 108.6 ± 31.6 μg fentanyl (P < .001) and 4.3 ± 1.2 mg midazolam (P < .001). Increased time from RYGB, higher American Society of Anesthesiologists class, and therapeutic procedure were associated with higher doses of sedation (P < .05). Thirty-two patients underwent EGD before and after RYGB. Patients were given 95.0 ± 39.0 μg fentanyl before RYGB and 130.5 ± 41.3 μg fentanyl afterward (P < .05); they were given 4.0 ± 1.0 mg midazolam before RYGB and 5.5 ± 1.7 mg midazolam afterward (P < .05). CONCLUSIONS Patients with RYGB require larger amounts of fentanyl and midazolam during EGD than patients without RYGB, despite similar age, sex, and BMI. Among patients who underwent EGD before and after RYGB, levels of drugs required for sedation increased after gastric bypass, despite weight loss.
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Walsh C, Karmali S. Endoscopic management of bariatric complications: A review and update. World J Gastrointest Endosc 2015. [PMID: 25992190 DOI: 10.4253/wjge.v7.i5.518.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.
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Affiliation(s)
- Caolan Walsh
- Caolan Walsh, Department of Surgery, Dalhousie University, Halifax, Nova Scotia B3H 2Y9, Canada
| | - Shahzeer Karmali
- Caolan Walsh, Department of Surgery, Dalhousie University, Halifax, Nova Scotia B3H 2Y9, Canada
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Walsh C, Karmali S. Endoscopic management of bariatric complications: A review and update. World J Gastrointest Endosc 2015; 7:518-523. [PMID: 25992190 PMCID: PMC4436919 DOI: 10.4253/wjge.v7.i5.518] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/06/2014] [Accepted: 02/12/2015] [Indexed: 02/05/2023] Open
Abstract
With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.
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Piché MÈ, Auclair A, Harvey J, Marceau S, Poirier P. How to choose and use bariatric surgery in 2015. Can J Cardiol 2014; 31:153-66. [PMID: 25661550 DOI: 10.1016/j.cjca.2014.12.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 01/01/2023] Open
Abstract
Severe obesity is associated with increased morbidity and mortality and represents a major health care problem with increasing incidence worldwide. Bariatric surgery, through its efficacy and improved safety, is emerging as an important available treatment for patients with severe obesity. Classically, bariatric surgery has been described as either a restrictive or a hybrid surgery, which is a combination of restriction and malabsorption. For most severely obese patients, bariatric surgery results in the remission of major obesity-related comorbidities including type 2 diabetes mellitus, sleep apnea, hypertension, and dyslipidemia. Thus, bariatric surgery reduces cardiovascular risk burden, and overall mortality risk. Early complications (< 30 days) after bariatric surgery were reported to be < 10% and tend to be lower in restrictive surgeries compared with hybrid surgeries. Most common early complications reported are gastric and anastomosis leak (1.6%-5.1%), bleeding (0.5%-3.5%), and pulmonary embolism (0.2%-1%). Long-term complications (> 30 days) might differ depending on the type of bariatric surgery. According to the type of surgery and the type of study, the 30-day operative mortality rates differ from 0.1% to 1.2%. Studies on postoperative outcomes, investigations on weight loss physiology, and mechanism of action after bariatric surgery provide a better understanding of the bariatric surgery metabolic benefits. In this article, we present an overview of bariatric procedures with their effects, including risks and benefits, on the severely obese patients' health. It provides evidence to support surgical treatment of severe obesity to achieve cardiovascular disease risk reduction in severely obese patients.
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Affiliation(s)
- Marie-Ève Piché
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - Audrey Auclair
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Québec, Canada
| | - Jany Harvey
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Québec, Canada
| | - Simon Marceau
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - Paul Poirier
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Québec, Canada.
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Mathus-Vliegen EMH. The cooperation between endoscopists and surgeons in treating complications of bariatric surgery. Best Pract Res Clin Gastroenterol 2014; 28:703-25. [PMID: 25194185 DOI: 10.1016/j.bpg.2014.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/18/2014] [Accepted: 07/05/2014] [Indexed: 02/09/2023]
Abstract
The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.
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Affiliation(s)
- E M H Mathus-Vliegen
- Academic Medical Centre, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Almadi MA, Bamihriz F, Aljebreen AM. Fatal aortoesophageal fistula bleeding after stenting for a leak post sleeve gastrectomy. World J Gastrointest Surg 2013; 5:337-340. [PMID: 24392186 PMCID: PMC3879419 DOI: 10.4240/wjgs.v5.i12.337] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 11/16/2013] [Indexed: 02/06/2023] Open
Abstract
Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents (SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwent a computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.
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Skomorowski M, Cappell MS. Endoscopic findings with severely symptomatic esophagitis from an overly restrictive laparoscopic adjustable gastric band. Surg Obes Relat Dis 2013; 10:e9-10. [PMID: 24094872 DOI: 10.1016/j.soard.2013.07.002] [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: 07/03/2013] [Accepted: 07/07/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Matthew Skomorowski
- Department of Internal Medicine, Riverside Methodist Hospital, Columbus, Ohio
| | - Mitchell S Cappell
- Division of Gastroenterology & Hepatology, William Beaumont Hospital, Royal Oak, Michigan.
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