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Masood M, Low DE, Deal SB, Kozarek RA. Endoscopic Management of Post-Sleeve Gastrectomy Complications. J Clin Med 2024; 13:2011. [PMID: 38610776 PMCID: PMC11012813 DOI: 10.3390/jcm13072011] [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: 02/09/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
| | - Donald E. Low
- Division of Thoracic Surgery, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Shanley B. Deal
- Division of General and Bariatric Surgery, Center for Weight Management, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Richard A. Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
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Kollmann L, Reimer S, Lock JF, Flemming I, Widder A, May J, Krietenstein L, Gruber M, Meining A, Hankir M, Germer CT, Seyfried F. Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience. Surg Obes Relat Dis 2023; 19:1041-1048. [PMID: 36948972 DOI: 10.1016/j.soard.2023.02.010] [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: 11/11/2022] [Revised: 01/04/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Gastric (anastomotic or staple-line) leaks after bariatric surgery are rare but potentially life-threatening complications. Endoscopic vacuum therapy (EVT) has evolved as the most promising treatment strategy for leaks associated with upper gastrointestinal surgery. OBJECTIVE The aim of this study was to evaluate the efficiency of our gastric leak management protocol in all bariatric patients over a 10-year period. Special emphasis was placed on EVT treatment and its outcome as a primary treatment or as a secondary treatment when other approaches failed. SETTING This study was performed at a tertiary clinic and certified center of reference for bariatric surgery. METHODS In this retrospective single-center cohort study, clinical outcomes of all consecutive patients after bariatric surgery from 2012 to 2021 are reported, with special emphasis placed on gastric leak treatment. The primary endpoint was successful leak closure. Secondary endpoints were overall complications (Clavien-Dindo classification) and length of stay. RESULTS A total of 1046 patients underwent primary or revisional bariatric surgery, of whom 10 (1.0%) developed a postoperative gastric leak. Additionally, 7 patients were transferred for leak management after external bariatric surgery. Of these, 9 patients underwent primary and 8 patients underwent secondary EVT after futile surgical or endoscopic leak management. The efficacy of EVT was 100%, and there were no deaths. Complications did not differ between primary EVT and secondary treatment of leaks. Length of treatment was 17 days for primary EVT versus 61 days for secondary EVT (P = .015). CONCLUSIONS EVT for gastric leaks after bariatric surgery led to rapid source control with a 100% success rate both as primary and secondary treatment. Early detection and primary EVT shortened treatment time and length of stay. This study underlines the potential of EVT as a first-line treatment strategy for gastric leaks after bariatric surgery.
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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Stanislaus Reimer
- Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ilona Flemming
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Anna Widder
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jana May
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Laura Krietenstein
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maximilian Gruber
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
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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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Kiriakopoulos A, Kounatidis N, Menenakos I, Kostrova M, Zografos K, Menenakos E. Non-stenting treatment versus endoscopic stent placement in staple line leaks after laparoscopic sleeve gastrectomy. Langenbecks Arch Surg 2022; 407:1863-1872. [PMID: 35333965 DOI: 10.1007/s00423-022-02498-5] [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: 01/14/2021] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Presentation of results of non-stenting treatment versus endoscopic stenting placement in gastric staple leaks after laparoscopic sleeve gastrectomy (LSG). METHODS Between January 2007 and August 2020, 1371 eligible patients underwent LSG. After gastric leak detection, patients were classified into treatment groups A (endoscopic stent placement) and B (non-stenting management). Overall hospital stay, the time to complete gastric leak resolution and the incidence of further operative management constituted the main outcome measures. Statistical analysis included descriptive statistics and linear regression tests as needed. RESULTS A total of 27 patients (19 F/8 M, median age: 44.8 years (range: 36-58) with median preoperative BMI: 43.5 kg/m2 (range: 37.0-48.7)) presented with gastric staple line leak (1.9%) - mean detection day 5.8 postop (range: 1-12). Eight patients enrolled in group A and 19 patients in group B. The mean hospital stay for group A was 41.2 days (range: 24-60) versus 15 days (range: 12-18) for group B (p < 0.001). Complete leakage resolution was observed at mean 42.4 days (range 25-60) for group A and 34.5 days (range: 28-40) for group B patients, (p = 0.025). Only 2 group A patients accomplished complete leak resolution without additional intervention. Five group A patients (62.5%) versus 4 group B patients (21.1%) needed operative intervention during the treatment course (p = 0.037). CONCLUSIONS Conservative, non-stenting treatment of staple line leaks after LSG is feasible and is associated with superior results in terms of hospital say and leak resolution in comparison to endoscopic stenting.
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Affiliation(s)
- Andreas Kiriakopoulos
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece.
| | - Nefeli Kounatidis
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece
| | - Ilias Menenakos
- Actuarial Science, Department of Statistics, London School of Economics, London, UK
| | - Maria Kostrova
- Actuarial Science, Department of Statistics, London School of Economics, London, UK
| | - Konstantinos Zografos
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece
| | - Evangelos Menenakos
- 5th Surgical Clinic, "Evgenideion Hospital", National and Kapodistrian University of Athens School of Medicine, Papadiamantopoulou 20 Str., PO: 11528, Athens, Greece.,1st Clinic, Division of Morbid Obesity and Metabolic Surgery, "Ippokrateion Hospital", National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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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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Chung Y, Park DG, Kim YJ. Endoscopic Management of Staple Line Leak after Bariatric Surgery: Surgeon's Perspective. Clin Endosc 2021; 54:805-809. [PMID: 33975425 PMCID: PMC8652167 DOI: 10.5946/ce.2020.298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/20/2021] [Indexed: 11/14/2022] Open
Abstract
Laparoscopic sleeve gastrectomy (LSG) has become a standalone primary procedure as a bariatric metabolic surgery since the early 2000s. The overall complication rate of LSG is reported to range from 2% to 15%. Staple line leakage (SLL) remains a major adverse event and occurs in approximately 1–6% of patients. Choosing the optimal treatment modality is a complex process. Clinicians must understand that nutritional support and drainage of fluid collection are essential for initial management. Conservative endoscopic management and sufficient drainage can resolve approximately 70% of SLLs. Endoscopic management of bariatric complications has been rapidly evolving in recent years and can be considered in all patients who are hemodynamically stable. We will review the available endoscopic management techniques, including stent placement (self-expanding stents and bariatric-specific stents), clipping, tissue sealant application, and internal drainage (double-pigtail stents [DPS] placement, endoscopic vacuum therapy, and septotomy). Stent placement remains the mainstream treatment for SLLs. However, healing with stents requires multiple sessions/stents and a long course of recovery. Endoscopic internal drainage is gaining popularity and has the potential to be a superior method. The importance of early intervention and combined endoscopic methods should be recognized.
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Affiliation(s)
- Yoona Chung
- Bariatric and Metabolic Surgery Center, H+ Yangji Hospital, Seoul, Korea
| | - Dae Geun Park
- Bariatric and Metabolic Surgery Center, H+ Yangji Hospital, Seoul, Korea
| | - Yong Jin Kim
- Bariatric and Metabolic Surgery Center, H+ Yangji Hospital, Seoul, Korea
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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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Dammaro C, Lainas P, Dumont JL, Tranchart H, Donatelli G, Dagher I. Endoscopic Internal Drainage Coupled to Prompt External Drainage Mobilization Is an Effective Approach for the Treatment of Complicated Cases of Sleeve Gastrectomy. Obes Surg 2019; 29:2929-2935. [DOI: 10.1007/s11695-019-03933-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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