Management of leakage and stenosis after sleeve gastrectomy

Jejunal stenosis as a sequela after laparoscopic sleeve gastrectomy for morbid obesity: a case series

Porto-mesenteric venous thrombosis (PMVT) is a rare complication that is encountered in less than 1% of patients following laparoscopic sleeve gastrectomy (LSG). This condition could be conservatively managed in stable patients with no evidence of peritonitis or bowel wall ischemia. Nonetheless, conservative management may be followed by ischemic small bowel stricture, which is poorly reported in the literature. Herein, we present our experience regarding three patients who presented with manifestations of jejunal stricture after initial successful conservative management of PMVT. Retrospective analysis of patients who developed jejunal stenosis as a sequela after LSG. The three included patients had undergone LSG with an uneventful post-operative course. All of them developed PMVT that was conservatively managed mainly by anticoagulation. After they were discharged, all of them returned with manifestations of upper bowel obstruction. Upper gastrointestinal series and abdominal computed tomography confirmed the diagnosis of jejunal stricture. The three patients were explored via laparoscopy, and resection anastomosis of the stenosed segment was performed. Bariatric surgeons should be aware of the association between PMVT, following LSG, and ischemic bowel strictures. That should help in the rapid diagnosis of the rare and difficult entity.

Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience

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.

Hybrid management with graham patch repair assisted with an OVESCO endoscopic system for a post-Nissen fundoplication gastric fistula: A case report

INTRODUCTION AND IMPORTANCE

Gastric fistula is a complication in gastrointestinal surgery. For decades, patients with gastric fistulas were treated surgically, with high morbidity and mortality. Minimally invasive treatment through endoscopic therapy with stents and interventionism has allowed improvements. We present a case of successful hybrid laparoscopy and endoscopy for the treatment of a post-Nissen fundoplication gastric fistula.

CASE PRESENTATION

A 44-year-old male underwent laparoscopic Nissen fundoplication surgery; at 10 days post-surgery, he presented with oral intolerance, abdominal pain, and laboratory results showing an inflammatory response. Imaging studies indicated intra-abdominal collection; therefore, a laparoscopy revision was performed; transoperative endoscopy confirmed intra-abdominal collection and a gastric fistula. In turn, we performed closure with an omentum patch through the fistula fixed with OVESCO by endoscopy, with successful results.

CLINICAL DISCUSSION

Gastric fistula is a difficult complication to treat because exposure to secretions causes inflammation. Endoscopic techniques are described for the closure of gastrointestinal fistulas; however, several aspects must be considered for their use. Hybrid laparoscopic and endoscopic treatment in the same surgery can be useful and served as a novel and successful option in our case.

CONCLUSION

Hybrid treatment with endoscopy and laparoscopy can be considered an optional approach for the management of gastric fistulas greater than 1 cm and of several days of evolution.

GASTRIC TWIST AFTER SLEEVE GASTRECTOMY: A PROPOSAL FOR ENDOSCOPIC CLASSIFICATION

ABSTRACT - BACKGROUND: The twisting of the gastric tube is one of the main causes of persistent reflux and food intolerance after sleeve gastrectomy (SG). To date, there is no classification for gastric twist after SG. OBJECTIVE: This study aimed to propose an endoscopic classification for this condition and outline the clinical profile of these patients with sleeve gastrectomy. METHODS: Patients in the postoperative period of SG presenting endoscopic findings of gastric twist were included. All patients underwent an esophagogastroduodenoscopy 12 months after SG. The classification proposed consists of three degrees: degree I: mild rotation of the staple line without relevant shrinkage of the gastric lumen; degree II: moderate rotation of the staple line, leading to a focal area of fixed narrowing that requires additional maneuvers for its transposition; and degree III: severe rotation of the staple line leading to stenosis, with increased difficulty for transposition or complete blockage. RESULTS: Out of 2,723 patients who underwent SG, 45 (1.6%) presented gastric twist. Most patients were female (85%), with mean age of 39±10.4 years. In all, 41 (91.1%) presented degree I, 3 (6.7%) presented degree II, and 1 (2.2%) had degree III. Most patients were asymptomatic (n=26). Vomiting was the most prevalent symptom (15.5%). Statistically significant correlation of twisting degrees was not observed for both the presence of symptoms and the degrees of esophagitis. CONCLUSION: Gastric twist after SG is rare, with generally mild and asymptomatic presentation. The endoscopic classification was not statistically related to clinical presentation but set the ground for further analysis.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

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.

Total Gastrectomy with Roux-en-Y Limb Reconstruction for Complex and Chronic Fistulas After Laparoscopic Sleeve Gastrectomy: Single-Center Experience

PURPOSE

When a leak after laparoscopic sleeve gastrectomy (LSG) becomes a chronic fistula, the best surgical treatment remains controversial. The aim of study was to review our experience concerning the treatment of chronic and complex fistulas after LSG.

MATERIALS AND METHODS

A retrospective analysis of patients with a gastric fistula following LSG who were treated at our center between January 2013 and December 2018 was performed. All patients included underwent a total gastrectomy with a Roux-en-Y reconstruction (TG) for LSG chronic fistula.

RESULTS

During the period considered, 13 patients had a chronic fistula and were treated with open TG. The primary leak evolved to a gastro-cutaneos fistula in three patients (23%), to a gastro-splenic fistula in two patients (15.4%), to a gastro-pleural fistula in four patients (30.8%), and to a gastro-bronchial fistula in four patients (30.8%). During TG, a splenectomy and a spleno-pancreatectomy were needed in the two cases of gastro-splenic fistula. Five patients (38.5%) developed an early complication. Two patients developed an esophago-jejunal anastomotic leak treated with a conservative approach (15.4%). No patients needed hospitalization in the intensive care unit. Overall mean length of stay was 19 days (8-30 days). Mean BMI before LSG was 36 (± 5 kg/m²), mean BMI before TG was 30.3 (± 5.2 kg/m²), and mean BMI 2 years after TG was 23.5 (± 2.9 kg/m²).

CONCLUSION

When a more conservative and less mutilating surgical option is not possible, open TG with esophago-jejunostomy remains a valuable salvage procedure in the case of complex and extensive fistulas after LSG.

Quantification of gastric sleeve stenosis using endoscopic parameters and image analysis

BACKGROUND AND AIMS

Sleeve gastrectomy has quickly become the most commonly performed bariatric surgery. In light of its increasing popularity, the prevalence of gastric sleeve stenosis (GSS) continues to rise. Management with serial pneumatic dilation is highly successful but underused because of a lack of quantitative diagnostic criteria. We aimed to develop quantifiable endoscopic criteria to characterize GSS based on the (1) ratio of narrowest to widest gastric lumen diameter, (2) endoscope angulation/trajectory required for passage, and (3) presence of bilious fluid pooling in the proximal sleeve and compare it with endoluminal functional lumen imaging probe (EndoFLIP) diameter and distensibility indices (DIs) and endoscopic documentation of gastric lumen morphology.

METHODS

We retrospectively reviewed a prospectively maintained database of patients undergoing endoscopy to assess for GSS. Endoscopic images were reviewed in a blinded fashion by 2 bariatric endoscopists. The narrowest and widest part of the gastric lumen diameters were noted on each image, in addition to a hypothetical trajectory required for endoscope passage. Using image processing software, we calculated the the ratio of diameters (ie, narrowest divided by widest) and angle of endoscope trajectory. The presence of bilious fluid pooling in the proximal gastric lumen was noted. These values were then compared with EndoFLIP parameters and endoscopic documentation of gastric lumen morphology.

RESULTS

Thirty patients met inclusion criteria, and 26 (87%) were found to have a stenosis on endoscopy. Of those, 9 (35%) were characterized as mild, 11 (42%) as moderate, and 6 (23%) as severe. There was no difference in demographic information between patients with and without stenosis. In patients with stenosis, mean EndoFLIP diameters and DIs were 12.9 ± 3.9 mm and 11.0 ± 6.8 mm²/mm Hg, respectively. In patients without stenosis, mean EndoFLIP diameters and DIs were 19.9 ± 2.9 mm and 21.5 ± 1.0 mm²/mm Hg, respectively. Patients with stenosis had significantly lower diameter ratios compared with those without stenosis (.27 ± .14 vs .48 ± .77, P = .01). Diameter ratios were also inversely related to severity of sleeve stenosis (β = -.08, P = .01). Patients with stenosis were also more likely to have fluid pooling (96.2% vs 25%, P < .001). There was no significant difference in the trajectory of endoscope passage between the 2 groups.

CONCLUSIONS

Endoscopic criteria for diagnosis of GSS are lacking. Our data suggest the ratio between the narrowest and widest gastric lumen diameters and presence of pooled fluid is associated with diagnosis of stenosis by EndoFLIP and gastric lumen morphology. Future studies to validate these criteria are needed.

Gastric Per-Oral Endoscopic Myotomy for Treatment of Chronic Proximal Staple Line Leak Precipitated by Downstream Stenosis

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric surgery. Although considered a safe procedure, adverse events such as staple line leak in the context of sleeve stenosis can result in significant patient morbidity and health economic burden. Correction of the downstream stenosis is mandatory for closure of the staple line leak. Conventional endoscopic therapies offer high initial success rates, though ultimately a significant proportion proceed to revision surgery. Gastric per-oral endoscopic myotomy (G-POEM) is a novel, minimally invasive procedure which allows for a full-thickness myotomy of the stenosed segment, potentially conferring similar anatomical correction to surgical seromyotomy. We present a case of recalcitrant chronic proximal staple line leak in the context of a downstream gastric stenosis managed by G-POEM.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

The Edmonton Obesity Staging System Predicts Perioperative Complications and Procedure Choice in Obesity and Metabolic Surgery-a German Nationwide Register-Based Cohort Study (StuDoQ|MBE)

OBJECTIVE

To examine the relationship between Edmonton Obesity Staging System (EOSS) and perioperative complications as well as surgical procedure.

BACKGROUND

The application of EOSS for the selection of patients with obesity is a more comprehensive measure of obesity-related diseases and a predictor of mortality than body mass index (BMI).

METHODS

This was a nationwide cohort study using prospectively inserted data from the German register for obesity and metabolic surgery StuDoQ|MBE. All patients undergoing sleeve gastrectomy (SG), Roux-en Y gastric bypass (RYGB), and one-anastomosis gastric bypass (OAGB) between February 2015 and July 2017 as a primary treatment for severe obesity were included. Data included gender, age, BMI, ASA score, EOSS, early postoperative complications next to the Clavien-Dindo grading system, readmission, and 30-day mortality.

RESULTS

A total of 9437 patients were included. The mean BMI was 49.5 kg/m² ± 7.8 (range 35-103.5). The total postoperative complication rate was 5.3%, with the highest rate in EOSS 3 (7.8%) and 4 (6.8%). Thirty-day mortality was 0.2% with the highest mortality after SG in EOSS 3 (1.16%) and EOSS 4 (0.92%) (p = 0.0068). Crosstabs showed a prevalence of Clavien-Dindo III and IV complications of 3.4% (SG), 3.6% (RYGB), and 1.6% (OAGB) in EOSS 2 (p = 0.0032) and 3.5% (SG), 5.1% (RYGB), and 5.6% (OAGB) in EOSS 3.

CONCLUSION

The highest postoperative complications and mortality occurred in patients with EOSS ≥ 3. SG and OAGB could be the procedure of choice to reduce perioperative morbidity; nevertheless, it has to be in mind that in EOSS ≥ 3, SG has the highest mortality.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03556059.

Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis

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.

Omentopexy with Glubran®2 for reducing complications after laparoscopic sleeve gastrectomy: results of a randomized controlled study

Background

Gastric fistulas, bleeding, and strictures are commonly reported after laparoscopic sleeve gastrectomy (LSG), that increase morbidity and hospital stay and may put the patient’s life at risk. We report our prospective evaluation of application of synthetic sealant, a modified cyanoacrylate (Glubran®2), on suture rime, associated with omentopexy, to identify results on LSG-related complications.

Methods

Patients were enrolled for LSG by two Bariatric Centers, with high-level activity volume. Intraoperative recorded parameters were: operative time, estimated intraoperative bleeding, conversion rate. We prospectively evaluated the presence of early complications after LSG during the follow up period. Overall complications were analyzed. Perioperative data and weight loss were also evaluated. A control group was identified for the study.

Results

Group A (treated with omentopexy with Glubran®2) included 96 cases. Control group included 90 consecutive patients. There were no differences among group in terms of age, sex and Body Mass Index (BMI). No patient was lost to follow-up for both groups. Overall complication rate was significantly reduced in Group A. Mean operative time and estimated bleeding did not differ from control group. We observed three postoperative leaks in Group B, while no case in Group A (not statistical significancy). We did not observe any mortality, neither reoperation. Weight loss of the cohort was similar among groups. In our series, no leaks occurred applying omentopexy with Glubran®2.

Conclusion

Our experience of omentopexy with a modified cyanoacrylate sealant may lead to a standardized and reproducible approach that can be safeguard for long LSG-suture rime.

Trial registration

Retrospective registration on clinicaltrials.gov PRS, with TRN NCT03833232 (14/02/2019).

Imaging following bariatric surgery: roux-en-Y gastric bypass, laparoscopic adjustable gastric banding and sleeve gastrectomy

Morbid obesity is an increasing health problem, and bariatric surgery is a popular treatment option. Radiologists must be familiar with performing and interpreting studies in this patient population. The typical post-operative findings of the Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG) procedures on upper gastrointestinal (UGI) series and computerized tomography (CT) are presented. An overview of the potential complications is provided in addition to a description of potential pitfalls in interpreting these studies.