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Verras GI, Mulita F, Lampropoulos C, Kehagias D, Curwen O, Antzoulas A, Panagiotopoulos I, Leivaditis V, Kehagias I. Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients. J Pers Med 2023; 13:1422. [PMID: 37763189 PMCID: PMC10532722 DOI: 10.3390/jpm13091422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/26/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.
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Affiliation(s)
- Georgios-Ioannis Verras
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
| | | | - Dimitrios Kehagias
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
| | - Oliver Curwen
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Andreas Antzoulas
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Ioannis Panagiotopoulos
- Department of Cardiothoracic Surgery, General Hospital of Athens “Ippokrateio”, 11527 Athens, Greece
| | - Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, Westpfalz-Klinikum, 67655 Kaiserslautern, Germany
| | - Ioannis Kehagias
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
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2
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Medas R, Rodrigues-Pinto E. Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks. Gastroenterol Res Pract 2023; 2023:9712555. [PMID: 37342388 PMCID: PMC10279499 DOI: 10.1155/2023/9712555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/20/2022] [Accepted: 11/25/2022] [Indexed: 06/22/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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3
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The Evolving Management of Leaks Following Sleeve Gastrectomy. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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4
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Park JY. Diagnosis and Management of Postoperative Complications After Sleeve Gastrectomy. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2022; 11:1-12. [PMID: 36685085 PMCID: PMC9848960 DOI: 10.17476/jmbs.2022.11.1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 01/24/2023]
Abstract
Sleeve gastrectomy (SG) has demonstrated excellent outcomes in terms of weight loss and resolution of obesity-related comorbidities as a single procedure. It has gained rapidly increasing popularity among bariatric surgeons and patients over the last two decades. This is due to its relative ease of use and less frequent morbidities related to the procedure. Even though the overall complication rate after SG is reported to be lower than conventional Roux-en-Y gastric bypass or biliopancreatic diversion, it still affects 1-10% of the patients undergoing SG, which is not negligible. Early postoperative complications that can occur within 30 days after SG include hemorrhage, leakage, sleeve stenosis, and reflux. Thromboembolic events are rare but can occur after surgery. Here, we review the incidence, diagnosis, and management of these early postoperative complications.
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Affiliation(s)
- Ji Yeon Park
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea.,Department of Surgery, Kyungpook National University Chilgok Hospital, Daegu, Korea
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5
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Martínez Hernández A, Beltrán Herrera H, Martínez García V, Ibáñez Belenguer M, Queralt Martín R, Maiocchi Segredo AK, Aliaga Hilario E, Laguna Sastre JM. Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2022; 32:1034-1048. [PMID: 35132569 DOI: 10.1007/s11695-022-05890-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results. METHODS We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients' clinical characteristics, duration and type of stent, other stent complications, and mortality. RESULTS A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52-89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32-22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94-17.14%). The agreement between reviewers for the collected data gave a Cohen's κ value of 1.0. No deaths were caused directly by complications with the stent placement. CONCLUSIONS Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.
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Affiliation(s)
| | | | | | | | | | | | | | - José Manuel Laguna Sastre
- Department of General Surgery, University General Hospital, Castellon, Spain.,Jaume I Univeristy, Castellon, Spain
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Billmann F, Pfeiffer A, Sauer P, Billeter A, Rupp C, Koschny R, Nickel F, von Frankenberg M, Müller-Stich BP, Schaible A. Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used. Obes Surg 2022; 32:64-73. [PMID: 34731416 PMCID: PMC8752538 DOI: 10.1007/s11695-021-05467-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Gastric staple line leakage (GL) is a serious complication of laparoscopic sleeve gastrectomy (LSG), with a specific mortality ranging from 0.2 to 3.7%. The current treatment of choice is stent insertion. However, it is unclear whether the type of stent which is inserted affects treatment outcome. Therefore, we aimed not only to determine the effectiveness of stent treatment for GL but also to specifically clarify whether treatment outcome was dependent on the type of stent (small- (SS) or megastent (MS)) which was used. PATIENTS AND METHODS A single-centre retrospective study of 23 consecutive patients was conducted to compare the outcomes of SS (n = 12) and MS (n = 11) for the treatment of GL following LSG. The primary outcome measure was the success rate of stenting, defined as complete healing of the GL without changing the treatment strategy. Treatment change or death were both coded as failure. RESULTS The success rate of MS was 91% (10/11) compared to only 50% (6/12) for SS (p = 0.006). An average of 2.3 ± 0.5 and 6.8 ± 3.7 endoscopies were required to achieve healing in the MS and SS groups respectively (p < 0.001). The average time to resumption of oral nutrition was shorter in the MS group (1.4 ± 1.1 days vs. 23.1 ± 33.1 days, p = 0.003). CONCLUSIONS Stent therapy is only effective and safe for the treatment of GL after LSG if a MS is used. Treatment with a MS may not only increase treatment success rates but may also facilitate earlier resumption of oral nutrition and shorten the duration of hospitalization.
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Affiliation(s)
- Franck Billmann
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Aylin Pfeiffer
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Peter Sauer
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Adrian Billeter
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Christian Rupp
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Ronald Koschny
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Felix Nickel
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | | | - Beat Peter Müller-Stich
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany.
| | - Anja Schaible
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
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7
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Feitosa PHF, Santa-Cruz F, Padilha MV, Siqueira LT, Kreimer F, Ferraz ÁA. Endoscopic Self-Expandable Stent for the Treatment of Gastric Fistula After Sleeve Gastrectomy: A Descriptive Review. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2021.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - Luciana T. Siqueira
- Real Hospital Português de Beneficência, Recife, Brazil
- Department of Surgery, Federal University of Pernambuco, Recife, Brazil
| | - Flávio Kreimer
- Real Hospital Português de Beneficência, Recife, Brazil
- Department of Surgery, Federal University of Pernambuco, Recife, Brazil
| | - Álvaro A.B. Ferraz
- Department of Surgery, Federal University of Pernambuco, Recife, Brazil
- Gastrointestinal Surgery Unit, Hospital Esperança—Rede D'Or São Luiz, Recife, Brazil
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8
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Gjeorgjievski M, Imam Z, Cappell MS, Jamil LH, Kahaleh M. A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks. J Clin Gastroenterol 2021; 55:551-576. [PMID: 33234879 DOI: 10.1097/mcg.0000000000001451] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus. OBJECTIVE To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed. DESIGN A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes. RESULTS Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise. CONCLUSION Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Zaid Imam
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mitchell S Cappell
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Laith H Jamil
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
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Luigiano C, Di Leo M, Eusebi LH, Barabino M, De Nicola E, Giovenzana M, Opocher E, Iabichino G, Palamara MA, Giacobbe G, Tortora A, Virgilio C, Abenavoli L, Pallio S, Consolo P. Management of Leaks Following Laparoscopic Sleeve Gastrectomy Using Specifically Designed Large Covered Metal Stents. Rev Recent Clin Trials 2021; 16:303-308. [PMID: 33563171 DOI: 10.2174/1574887116666210204142417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/22/2020] [Accepted: 01/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Leaks are the major complication associated with laparoscopic sleeve gastrectomy. OBJECTIVE The study aimed to assess the efficacy and safety of specifically designed large covered metal stents for the management of post-laparoscopic sleeve gastrectomy leaks. METHODS Prospectively collected databases from three Italian Endoscopy Units were reviewed. The primary outcome of the study was to evaluate the clinical success of stents placement, defined as complete resolution of clinical and laboratory signs of sepsis with radiological evidence of leak closure. Secondary outcomes were stent-related adverse events and mortality. RESULTS Twenty-one patients (67% females, mean age 45 years) were included in the study and a total of 26 stents were placed. Technical success of stent placement was achieved in all cases (100%). Clinical success was observed in 85.5% of patients. Stent-related adverse events occurred in 9 patients (43%), with stent migration as the most frequent complication (33%). Adverse events were more frequently observed in patients who had undergone bariatric surgery prior to laparoscopic sleeve gastrectomy compared to patients without previous surgery (83% et al. 27%, p=0.018). CONCLUSION The placement of specifically designed covered metal stents appears to be an effective and safe therapeutic approach for post-laparoscopic sleeve gastrectomy leaks. Stent migration can be a frequent complication.
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Affiliation(s)
- Carmelo Luigiano
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Milena Di Leo
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Leonardo Henry Eusebi
- Gastroenterology and Endoscopy Unit, Department of Medical and Surgical Sciences, S. Orsola University Hospital, Via G. Massarenti, 9, 40138 Bologna, Italy
| | - Matteo Barabino
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Enrico De Nicola
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Marco Giovenzana
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Enrico Opocher
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Giuseppe Iabichino
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Maria Angela Palamara
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Giuseppa Giacobbe
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
| | - Andrea Tortora
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
| | - Clara Virgilio
- Unit of Gastroenterology and Digestive Endoscopy, ARNAS Garibaldi, 95122 Catania, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University "Magna Graecia", Viale Europa - 88100 Catanzaro, Italy
| | - Socrate Pallio
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
| | - Pierluigi Consolo
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
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10
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Outcome and Adverse Events of Endoscopic Bariatric Stents for Management of Leakage after Bariatric Surgery. Obes Surg 2021; 30:982-991. [PMID: 31902044 DOI: 10.1007/s11695-019-04373-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Bariatric leakage (BL) is a serious complication with a variety in available treatment options. Endoscopic stenting is preferred because of its minimally invasive nature in morbidly obese patients. Various modifications have been applied to stents since its use in palliation of malignant strictures. Few studies have exclusively evaluated the efficacy of bariatric stents in management BL. METHODS A retrospective cohort study of patients with BL managed by bariatric stents in the period between July 2014 and January 2019. The primary outcome was the clinical success in healing of leakage and secondary outcomes included adverse events (AEs), hospital stay and procedure-related mortality. RESULTS Forty-five patients were included in this study. Clinical success occurred in 33 patients (73.3%). There was no stent-related mortality. The most frequent stent-related complications were reflux (62.2%), intolerance (55.6%), and migration (17.8%). Severe AEs occurred in 9 patients (20%). The overall complications rate was higher in diabetic patients (P = 0.048). Intolerance was significantly associated with shorter interval to management (P = 0.02). Stent migration was higher in male patients (P = 0.019) and higher BMI (P = 0.024). CONCLUSION Endoscopic stenting is a double-edged weapon that must be handled cautiously. It is a highly effective therapy, and early intervention is the main determinant of its efficacy. But it is not a treatment without complications (80%). The variant and high prevalence of complications mandates a strict follow-up throughout the stenting duration.
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Hany M, Ibrahim M, Zidan A, Samir M, Elsherif A, Selema M, Sharaan M, Elhashash M. 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. Obes Surg 2021; 31:2050-2061. [PMID: 33409972 DOI: 10.1007/s11695-020-05211-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Mohamed Hany
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt.
| | - Mohamed Ibrahim
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Ahmed Zidan
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Samir
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Amr Elsherif
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Selema
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Sharaan
- Department of Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohamed Elhashash
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
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12
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Hamid HKS, Emile SH, Saber AA, Dincer M, de Moura DTH, Gilissen LPL, Almadi MA, Montuori M, Vix M, Perisse LGS, Quezada N, Garofalo F, Pescarus R. Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis. Surg Endosc 2020; 35:1025-1038. [DOI: 10.1007/s00464-020-08147-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
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13
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Iglesias Jorquera E, Egea Valenzuela J, Serrano Jiménez A, Carrilero Zaragoza G, Ortega Sabater A, Sánchez Velasco E, Ruiz de Angulo D, Munitiz V, Parrilla P, Alberca de Las Parras F. Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:14-22. [PMID: 33118355 DOI: 10.17235/reed.2020.6821/2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option. AIMS the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks. METHODS a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018. RESULTS twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach. CONCLUSIONS endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.
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Affiliation(s)
| | - Juan Egea Valenzuela
- Aparato Digestivo , Hospital Clínico Universitario Virgen de la Arrixaca, España
| | | | | | | | | | | | - Vicente Munitiz
- Cirugía, Hospital Clinico Universitario Virgen de la Arrixaca
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Schulman AR, Watson RR, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Jirapinyo P, Krishnan K, Kumta NA, Melson J, Pannala R, Parsi MA, Trikudanathan G, Trindade AJ, Maple JT, Lichtenstein DR. Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos). Gastrointest Endosc 2020; 92:492-507. [PMID: 32800313 DOI: 10.1016/j.gie.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type. METHODS The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized. RESULTS Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving. CONCLUSIONS Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.
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Affiliation(s)
- Allison R Schulman
- Department of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Incidence and Efficacy of Stent Placement in Leak Management After Bariatric Surgery: An MBSAQIP Analysis. Ann Surg 2020; 271:134-139. [PMID: 30247333 DOI: 10.1097/sla.0000000000003023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the rates of use and efficacy of stent placement for postoperative leak following bariatric surgery. SUMMARY OF BACKGROUND DATA Endoscopically placed stents can successfully treat anastomotic and staple line leaks after bariatric surgery. However, the extent to which stents are used in the management of bariatric complications and rates of reoperation remain unknown. METHODS Data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use files were analyzed for patients who experienced anastomotic or staple line leaks after bariatric surgery, and then evaluated for use of an endoscopically placed stent. Patient and procedure-level data were compared between those who underwent stent placement versus those who required reoperation. Multivariable logistic regression was used to compare outcomes between groups. RESULTS A total of 354,865 bariatric cases were captured in 2015 to 2016. One thousand one hundred thirty patients (0.3%) required intervention for a leak, of whom 275 (24%) were treated with an endoscopically placed stent. One hundred seven (39%) of the patients who received stents required reoperation as part of their care pathway. Patient characteristics were statistically similar when comparing leaks managed with stents to those treated with reoperation alone. Those treated with stents, however, had a higher likelihood of readmission (odds ratio 2.59, 95% confidence interval -1.59 to 4.20). CONCLUSION Placement of stents for management of leaks after bariatric surgery is common throughout the United States. The use of stents can be effective; however, it does not prevent reoperation and is associated with an increased likelihood of readmission. Both technique and resource utilization should be considered when choosing a management pathway for leaks.
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Rogalski P, Swidnicka-Siergiejko A, Wasielica-Berger J, Zienkiewicz D, Wieckowska B, Wroblewski E, Baniukiewicz A, Rogalska-Plonska M, Siergiejko G, Dabrowski A, Daniluk J. Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis. Surg Endosc 2020; 35:1067-1087. [PMID: 32107632 PMCID: PMC7886733 DOI: 10.1007/s00464-020-07471-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
Background Endoscopic techniques have become the first-line therapy in bariatric surgery-related complications such as leaks and fistulas. We performed a systematic review and meta-analysis on the effectiveness of self-expandable stents, clipping, and tissue sealants in closing of post-bariatric surgery leak/fistula. Methods A systematic literature search of the Medline/Scopus databases was performed to identify full-text articles published up to February 2019 on the use of self-expandable stents, clipping, or tissue sealants as primary endoscopic strategies used for leak/fistula closure. Meta-analysis of studies reporting stents was performed with the PRISMA guidelines. Results Data concerning the efficacy of self-expanding stents in the treatment of leaks/fistulas after bariatric surgery were extracted from 40 studies (493 patients). The overall proportion of successful leak/fistula closure was 92% (95% CI, 90–95%). The overall proportion of stent migration was 23% (95% CI, 19–28%). Seventeen papers (98 patients) reported the use of clipping: the over-the-scope clips (OTSC) system was used in 85 patients with a successful closure rate of 67.1% and a few complications (migration, stenosis, tear). The successful fistula/leak closure using other than OTSC types was achieved in 69.2% of patients. In 10 case series (63 patients), fibrin glue alone was used with a 92.8–100% success rate of fistula closure that usually required repeated sessions at scheduled intervals. The complications of fibrin glue applications were reported in only one study and included pain and fever in 12.5% of patients. Conclusions Endoscopic techniques are effective for management of post-bariatric leaks and fistulas in properly selected patients. Electronic supplementary material The online version of this article (10.1007/s00464-020-07471-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Agnieszka Swidnicka-Siergiejko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland.
| | - Justyna Wasielica-Berger
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Damian Zienkiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Barbara Wieckowska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Rokietnicka 7 St. (1st floor), 60-806, Poznan, Poland
| | - Eugeniusz Wroblewski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Andrzej Baniukiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Magdalena Rogalska-Plonska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Grzegorz Siergiejko
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Jaroslaw Daniluk
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
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Okazaki O, Bernardo WM, Brunaldi VO, Junior CCDC, Minata MK, de Moura DTH, de Souza TF, Campos JM, Santo MA, de Moura EGH. Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2019; 28:1788-1796. [PMID: 29654447 DOI: 10.1007/s11695-018-3236-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.
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Affiliation(s)
- Ossamu Okazaki
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil.
| | - Wanderley M Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Vitor O Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Cesar C de Clemente Junior
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Maurício K Minata
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Diogo T H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Thiago F de Souza
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | | | - Marco Aurélio Santo
- Bariatric and Metabolic Surgery Unit, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Eduardo G H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
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18
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Mirhashemi S, Malekpour Alamdari N, Jaberi N, Shahrbaf MA. Prevalence of Anastomotic Leaks and Diagnostic Methods in Sleeve Gastrectomy. Bariatr Surg Pract Patient Care 2019. [DOI: 10.1089/bari.2018.0056] [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)
- Seyedhadi Mirhashemi
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasser Malekpour Alamdari
- Department of General Surgery, Modarres, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Najmeh Jaberi
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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19
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Badurdeen DS, Lamond K, Gandsas A, Kumbhari V. Endoscopic strategies for the treatment of postbariatric surgery leaks and fistulas. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Ortega CB, Guerron AD, Portenier D. Endoscopic Abscess Septotomy: A Less Invasive Approach for the Treatment of Sleeve Gastrectomy Leaks. J Laparoendosc Adv Surg Tech A 2018; 28:859-863. [DOI: 10.1089/lap.2017.0429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Camila B. Ortega
- Division of Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Alfredo D. Guerron
- Division of Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Dana Portenier
- Division of Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
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21
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Martin del Campo SE, Mikami DJ, Needleman BJ, Noria SF. Endoscopic stent placement for treatment of sleeve gastrectomy leak: a single institution experience with fully covered stents. Surg Obes Relat Dis 2018; 14:453-461. [DOI: 10.1016/j.soard.2017.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 12/04/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
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22
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Boerlage TCC, Houben GPM, Groenen MJM, van der Linde K, van de Laar AWJM, Emous M, Fockens P, Voermans RP. A novel fully covered double-bump stent for staple line leaks after bariatric surgery: a retrospective analysis. Surg Endosc 2018; 32:3174-3180. [PMID: 29344787 PMCID: PMC5988771 DOI: 10.1007/s00464-018-6034-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 01/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Staple line leakage after bariatric surgery can be treated by endoscopic placement of a self-expandable stent. The success rate of stent placement is generally high, but migration is a frequent adverse event that hampers successful treatment. The Niti-S Beta stent is a fully covered double-bump stent that was specifically designed to prevent migration. This study aimed to evaluate the effectiveness and adverse event rate of the Niti-S Beta stent. METHODS A retrospective study was performed in three high-volume bariatric centers. All consecutive patients between 2009 and 2016 who underwent placement of a Beta stent for staple line leakage were included. Primary outcome was resolution of the leakage; secondary outcome was the adverse event rate including migration. RESULTS Thirty-eight patients were included. Twenty-five (66%) had resolution of the leakage. Success rate was higher in patients who were treated with implantation of a Beta stent as initial treatment (100%) than in patients who were treated with a stent after revisional surgery had failed (55%, p = 0.013). Migration occurred in 12 patients (32%). There were two severe adverse events requiring surgical intervention, including a bleeding from an aorto-esophageal fistula. CONCLUSIONS The success rate and the migration rate of the Beta stent seem comparable to other stents in this retrospective study. Despite the novel double-bump structure of the stent, the migration rate does not seem to be decreased.
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Affiliation(s)
- Thomas C C Boerlage
- Department of Internal Medicine, MC Slotervaart, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands. .,Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Gerardus P M Houben
- Department of Gastroenterology & Hepatology, MC Slotervaart, Amsterdam, The Netherlands
| | - Marcel J M Groenen
- Department of Gastroenterology & Hepatology, Rijnstate ziekenhuis, Arnhem, The Netherlands
| | - Klaas van der Linde
- Department of Gastroenterology & Hepatology, MC Leeuwarden, Leeuwarden, The Netherlands
| | | | - Marloes Emous
- Department of Surgery, MC Leeuwarden, Leeuwarden, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Gastroenterology & Hepatology, MC Slotervaart, Amsterdam, The Netherlands
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23
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Shehab H. Enteral stents in the management of post-bariatric surgery leaks. Surg Obes Relat Dis 2017; 14:393-403. [PMID: 29428690 DOI: 10.1016/j.soard.2017.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/10/2017] [Accepted: 12/13/2017] [Indexed: 02/07/2023]
Abstract
A post-bariatric surgery leak is a rare but grave condition and remains every bariatric surgeon's nightmare. Endoscopic therapy with the insertion of self-expandable stents provides an effective minimally invasive approach for the management of leaks. Self-expandable stents, however, are still hampered by their tendency for migration and are not always well tolerated. Recently, double-pigtail stents have been proposed as an alternative endoscopic therapeutic modality. Both types of stents have been shown to be very effective in the management of leaks; however, most studies have pooled gastrointestinal leaks due to different etiologies together. In this article, we review the current status and foreseen innovations in gastrointestinal stenting for post-bariatric surgery leaks.
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Affiliation(s)
- Hany Shehab
- Gastrointestinal Endoscopy unit, Department of Gastroenterology, Cairo University, Cairo, Egypt.
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24
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Guerron AD, Ortega CB, Portenier D. Endoscopic Abscess Septotomy for Management of Sleeve Gastrectomy Leak. Obes Surg 2017; 27:2672-2674. [PMID: 28695456 DOI: 10.1007/s11695-017-2809-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Alfredo D Guerron
- Department of Surgery, Division of Metabolic and Weight Loss Surgery, Duke University Health System, Durham, NC, USA.
| | - Camila B Ortega
- Department of Surgery, Division of Metabolic and Weight Loss Surgery, Duke University Health System, Durham, NC, USA
| | - Dana Portenier
- Department of Surgery, Division of Metabolic and Weight Loss Surgery, Duke University Health System, Durham, NC, USA
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25
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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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26
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Joo MK. Endoscopic Approach for Major Complications of Bariatric Surgery. Clin Endosc 2016; 50:31-41. [PMID: 28008162 PMCID: PMC5299989 DOI: 10.5946/ce.2016.140] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022] Open
Abstract
As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.
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Affiliation(s)
- Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul, Korea
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27
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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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