Stent migration causing alimentary limb obstruction necessitating laparotomy and surgical stent extraction

Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly performed bariatric/metabolic operation in Europe. Different treatment options for the management of gastrojejunal (GJ) leaks following LRYGB have been published. We looked at our own experience with GJ leaks after 645 consecutive LRYGB operations and reviewed the literature with focus on the use of fibrin sealant and self-expandable metal stents as treatment options. Patient data were prospectively collected in the hospital's database for bariatric patients. All patients with confirmed GJ leaks were reviewed. Patients with GJ leaks were actively treated by a combination of laparoscopic drainage and endoscopic fibrin sealant injections and/or stenting. Six patients (0.93%) have been treated for GJ leaks. All leaks were successfully treated and there was no leak-related mortality. The mean (SD) time for closure of the leaks and length of hospital stay was 19.5 days (6.2) and 23.2 days (3.7). The literature concerning endoscopic treatment options in case of GJ leaks following LRYGB operations is scarce and inconclusive. Immediate and active treatment with a combination of operative and endoscopic treatment options, rather than choosing only one treatment over another, may enhance the recovery process.

Partially covered esophageal stents cause bowel injury when used to treat complications of bariatric surgery

BACKGROUND

We hypothesized that an esophageal nitinol stent that is mainly silicone-covered but partially uncovered may allow tissue ingrowth and decrease the migration rate seen with fully covered stents and still allow safe stent removal. The aim of this study was to evaluate the first human results of using partially covered stents for anastomotic complications of bariatric surgery.

METHODS

This was a retrospective evaluation of all patients with staple-line complications after bariatric surgery who received a partly covered stent at a single tertiary-care bariatric center. The stents varied in length from 10 to 15 cm and in diameter from 18 to 23 mm.

RESULTS

From April 2009 to April 2010, eight patients received partially covered stents on 14 separate occasions. The indications were gastrojejunal stricture in four, acute leak in two, acute leak followed by a later stricture in one, and a perforated anastomotic ulcer in one patient. Single stents were placed in 12 sessions and two overlapping stents in two sessions. At the time of stent deployment, one patient had the uncovered proximal end of the stent in the stomach, with all others in the distal esophagus. Immediate symptom improvement occurred in 12/14 stent placements. Oral nutrition was initiated for 10/14 stent treatments within 48 h. Stents were removed after 25 ± 10 days. Minor stent displacement occurred with 9/13 stents, with the proximal end of the stent moving into the stomach, though the site of pathology remained covered. The stents were difficult to remove when tissue ingrowth was present. One patient required laparoscopic removal and one required two endoscopy sessions for removal. At the time of removal of ten stents, where the proximal end was found in the stomach, four had gastric ulceration, three had gastric mucosa replaced by granulation tissue, and three had normal gastric mucosa. In four cases where the proximal portion of the stent stayed in the esophagus, the esophageal deployment zone had abnormalities: three with granulation tissue and one with denuding of the esophageal mucosa. The distal uncovered portion of the stent in the Roux limb never became embedded in the mucosa and caused minimal injury.

CONCLUSIONS

A partially covered stent was successful in keeping the site of the pathology covered and provided rapid symptom improvement and oral nutrition in most patients. The proximal end of the stent generally moved from the esophagus to the stomach, probably due to esophageal peristalsis. The proximal uncovered portion of the stent causes significant bowel mucosal injury and sometimes becomes embedded in the esophagus or the stomach, making removal difficult. We no longer use partially covered stents.

Early migration of fully covered double-layered metallic stents for post-gastric bypass anastomotic strictures

INTRODUCTION

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is well recognized for its efficiency in morbidly obese patients. Anastomotic strictures present in 5-15% of cases and have a significant impact on the patient's quality of life. Endoscopic balloon dilation is the recommended treatment but management of refractory cases is challenging.

PRESENTATION OF CASE

Two patients with anastomotic stenoses refractory to dilations were treated with fully covered esophageal stents. Both cases presented early stent migration. The first patient finally underwent surgical revision of the anastomosis. For the second patient, a double-layered stent was installed after the first incident. After the migration of this second stent, three sessions of intralesional injection of triamcinolone acetonide were performed. Both patients were free of obstructive symptoms at a follow-up of 9 months.

DISCUSSION

Treatment of post-gastric bypass strictures with stents is based on years of successful experience with endoscopic stenting of malignant esophageal strictures, gastric outlet obstruction in addition to anastomotic stenoses after esophageal cancer surgery. The actual prosthesis are however inadequate for the particularities of the LRYGB anastomosis with a high migration rate. Intralesional corticosteroid injection therapy has been reported to be beneficial in the management of refractory benign esophageal strictures and seems to have prevented recurrence of the stenosis in this post-LRYGB.

CONCLUSION

Stents are aimed at preventing a complex surgical reintervention but are not yet specifically designed for that indication. Local infiltration of corticosteroids at the time of dilation may prevent recurrence of the anastomotic stricture.