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Bawa JH, Sulutaura L, Patel NM, Sufi PA, Parmar C. Closure of Gastrocutaneous Fistula Following Bariatric Surgery: a Systematic Review. Obes Surg 2023; 33:3658-3668. [PMID: 37804467 DOI: 10.1007/s11695-023-06861-3] [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: 07/02/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023]
Abstract
Gastrocutaneous fistula (GCF) is a devastating complication that can arise after bariatric and metabolic surgery (BMS). This systematic review examines the success rate of closure techniques of GCF. A systematic search was conducted across MEDLINE, Embase and Cochrane databases to identify studies which reported on closure techniques of GCF after BMS in adults. Thirty-three studies (n = 108 patients) were included. Seventeen different techniques were used to close GCF across all studies. The most popular were stents (n = 17), tissue sealants (n = 12) and over-the-scope clips (n = 11). Twenty-one studies used multiple techniques to attempt closure, including endoscopic vacuum therapy and revisional surgery. This systematic review demonstrates current practice focusing on endoscopic methods such as stents and over-the-scope clips, with relative success in closing GCF.
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Affiliation(s)
- Jasmine H Bawa
- Department of Upper GI and Bariatric Surgery, Whittington Health NHS Trust, Magdala Ave, London, N19 5NF, UK
| | - Liene Sulutaura
- Department of Upper GI and Bariatric Surgery, Whittington Health NHS Trust, Magdala Ave, London, N19 5NF, UK
| | - Nikhil M Patel
- Department of Upper GI and Bariatric Surgery, Whittington Health NHS Trust, Magdala Ave, London, N19 5NF, UK
| | - Pratik A Sufi
- Department of Upper GI and Bariatric Surgery, Whittington Health NHS Trust, Magdala Ave, London, N19 5NF, UK
| | - Chetan Parmar
- Department of Upper GI and Bariatric Surgery, Whittington Health NHS Trust, Magdala Ave, London, N19 5NF, UK.
- Barts Health NHS Trust, London, EC1A 7BE, UK.
- Apollo Hospitals Research and Education Foundation, Delhi, 50096, India.
- University College London, Gower St, London, WC1E 6BT, UK.
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2
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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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3
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Abstract
Gastrointestinal surgery is increasingly being performed. Despite improving technology and outcomes, complications are not completely avoidable. Frequently, surgical complications require invasive procedures for management. However, with increasing availability of flexible endoscopy and a wider array of tools, more often these complications can be managed with an endolumenal approach. This article is an in-depth review of endoscopic management of surgical complications.
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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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Younis F, Shnell M, Gluck N, Abu-Abeid S, Eldar S, Fishman S. Endoscopic treatment of early leaks and strictures after laparoscopic one anastomosis gastric bypass. BMC Surg 2020; 20:33. [PMID: 32085769 PMCID: PMC7035723 DOI: 10.1186/s12893-020-0686-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/22/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Laparoscopic one anastomosis gastric bypass has become a prominent bariatric procedure. Yet, early and late complications, primarily leaks and strictures, are not uncommon. This study summarizes our experience with endoscopic treatment of laparoscopic one anastomosis gastric bypass complications. METHODS This is a retrospective study of consecutive patients referred to our hospital from 2015 to 2017 with post laparoscopic one anastomosis gastric bypass complications. Therapy was tailored to each case, including fully covered self-expandable metal stents, fibrin glue, septotomy, internal drainage with pigtail stents, through-the-scope and pneumatic dilation. Success was defined as resuming oral nutrition without enteral or parenteral support or further surgical intervention. RESULTS Nine patients presented with acute or early leaks: 5 (56%) had staple-line leaks, 3 (33%) had anastomotic leaks and 1 (11%) had both. All were treated with stents. Adjunctive endoscopic drainage was applied in 4 patients (44%). Overall 5 patients (56%) with acute/ early leaks recovered completely, including all 3 patients with anastomotic leak and the patient with both leaks but only 1/5 with staple line leak (20%). Complication rate in the leak group reached 22%. Eight patients presented with strictures, 7 at the anastomosis and one due to remnant stomach misalignment. All anastomotic strictures were dilated successfully. However, the patient with the pouch stricture required conversion to Roux-en-Y gastric bypass after 3 failed attempts of dilation. CONCLUSION Endoscopic treatments of laparoscopic one anastomosis gastric bypass complications are relatively effective and safe. Anastomosis-related complications are more amenable to endoscopic treatment compared to staple line leaks.
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Affiliation(s)
- Fadi Younis
- Obesity Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with Sackler School of Medicine, Tel Aviv University, 6 Weizmann St, Tel Aviv, Israel
| | - Mati Shnell
- Obesity Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with Sackler School of Medicine, Tel Aviv University, 6 Weizmann St, Tel Aviv, Israel
| | - Nathan Gluck
- Obesity Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with Sackler School of Medicine, Tel Aviv University, 6 Weizmann St, Tel Aviv, Israel
| | - Subhi Abu-Abeid
- Bariatric Unit, Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shai Eldar
- Bariatric Unit, Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sigal Fishman
- Obesity Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with Sackler School of Medicine, Tel Aviv University, 6 Weizmann St, Tel Aviv, Israel.
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Percutaneous Image-Guided Abdominal Interventions for Leaks and Fistulas Following Sleeve Gastrectomy and Roux-en-Y Gastric Bypass. Obes Surg 2019; 29:2051-2058. [DOI: 10.1007/s11695-019-03824-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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7
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Batterham SP. Repair of gastrocutaneous fistula utilizing thickened fluids: application of Poiseuille's Law to fistula healing. J Surg Case Rep 2018; 2018:rjy162. [PMID: 30002806 PMCID: PMC6037113 DOI: 10.1093/jscr/rjy162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/06/2018] [Accepted: 06/21/2018] [Indexed: 11/12/2022] Open
Abstract
Enterocutaneous fistulas are a rare occurrence after placement of a PEG tube. The key risk factor for their development is the time the PEG tube is in situ, giving time for the fistula tract to mature. Enterocutaneous fistulae are traditionally treated with parenteral nutrition or surgical management. We present a case of a 69-year-old woman who underwent surgical closure of an enterocutaneous fistula with a fibrin plug. The fistula recurred on post-operative Day 5, and the patient was placed on thickened fluids to increase the viscosity of the fluid exiting the fistula tract. This approach decreased the output and lead to subsequent closure of the fistula by outpatient follow up at 4 weeks. This case demonstrates an application of Poiseuille's law to closure of fistula tracts.
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Affiliation(s)
- Simon P Batterham
- The Maitland Hospital, 560 High St, Maitland, New South Wales, Australia
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8
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Gonzalez JM, Lorenzo D, Guilbaud T, Bège T, Barthet M. Internal endoscopic drainage as first line or second line treatment in case of postsleeve gastrectomy fistulas. Endosc Int Open 2018; 6:E745-E750. [PMID: 29876512 PMCID: PMC5988543 DOI: 10.1055/s-0044-101450] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Management of post-sleeve gastrectomy fistulas (PSGF) recently has evolved, resulting in prioritization of internal endoscopic drainage (IED). We report our experience with the technique in a tertiary center. PATIENTS AND METHODS This was a single-center, retrospective study of 44 patients whose PSGF was managed with IED, comparing two periods: after 2013 (Group 1; n = 22) when IED was used in first line and before 2013 (Group 2; n = 22) when IED was applied in second line. Demographic data, pre-endoscopic management, characteristics of fistulas, therapeutic modalities and outcomes were recorded and compared between the two groups. The primary endpoint was IED efficacy; the secondary endpoint was a comparison of outcomes depending on the timing of IED in the management strategy. RESULTS The groups were matched in gender (16 female, 16 male), mean age (43 years old), severity of fistula, delay before treatment, and exposure to previous endoscopic or surgical treatments. The overall efficacy rate was 84 % (37/44): 86 % in Group 1 and 82 % in Group 2 (NS). There was one death and one patient who underwent surgery. The median time to healing was 226 ± 750 days (Group 1) vs. 305 ± 300 days (Group 2) (NS), with a median number of endoscopies of 3 ± 6 vs . 4.5 ± 2.4 (NS). There were no differences in number of nasocavity drains and double pigtail stents (DPS), but significantly more metallic stents, complications, and secondary strictures were seen in Group 2. CONCLUSION IED for management of PSGF is effective in more than 80 % of cases whenever it is used during the therapeutic strategy. This approach should be favored when possible.
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Affiliation(s)
- J. M. Gonzalez
- Aix-Marseille Univ, APHM, Service de gastroentérologie, Hôpital Nord, Marseille, France,Corresponding author Jean-Michel Gonzalez, MD, MSc Service de GastroentérologieHôpital Nord, AP-HMChemin des Bourrelys13015, MarseilleFrance+04 91 96 87 37
| | - D. Lorenzo
- Aix-Marseille Univ, APHM, Service de gastroentérologie, Hôpital Nord, Marseille, France
| | - T. Guilbaud
- Aix-Marseille Univ, APHM, Service de chirurgie digestive, Hôpital Nord, Marseille, France
| | - T. Bège
- Aix-Marseille Univ, APHM, Service de chirurgie digestive, Hôpital Nord, Marseille, France
| | - M. Barthet
- Aix-Marseille Univ, APHM, Service de gastroentérologie, Hôpital Nord, Marseille, France
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Assalia A, Ilivitzki A, Ofer A, Suissa A, Manassa E, Khamaysi I, Mahajna A. Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach. Surg Obes Relat Dis 2018; 14:1093-1098. [PMID: 29895427 DOI: 10.1016/j.soard.2018.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 03/31/2018] [Accepted: 04/15/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality. OBJECTIVES To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG. SETTING University hospital, Israel. METHODS Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m2) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage. RESULTS There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46). CONCLUSIONS Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.
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Affiliation(s)
- Ahmad Assalia
- Department of General Surgery, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Anat Ilivitzki
- Department of Radiology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Amos Ofer
- Department of Radiology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Alain Suissa
- Department of Gastroenterology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Elias Manassa
- Department of General Surgery, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Iyad Khamaysi
- Department of Gastroenterology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Ahmad Mahajna
- Department of General Surgery, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Kim SY, Oh KY, Chung JW, Kim YJ, Kim KO, Kwon KA, Park DK, Kim KK, Kim SM. Endoscopic Treatment of Diverse Complications Caused by Laparoscopic Adjustable Gastric Banding: A Study in Eastern Asia. Gut Liver 2018; 11:497-503. [PMID: 28335099 PMCID: PMC5491084 DOI: 10.5009/gnl16089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/07/2016] [Accepted: 10/13/2016] [Indexed: 01/16/2023] Open
Abstract
Background/Aims The use of laparoscopic adjustable gastric banding (LAGB) is increasing proportionally with the obesity epidemic. However, some postoperative complications have been highlighted as major problems associated with LAGB. There is no consensus concerning the endoscopic management of these adverse events. The aim of this study was to retrospectively review the feasibility and effectiveness of endoscopic treatment for LAGB complications. Methods We retrospectively evaluated 352 patients who underwent LAGB between 2011 and 2015. LAGB-associated complications developed in 26 patients (7.4%). This study involved six patients (1.7%) who received endoscopic treatment. Results Types of LAGB-induced complications in our series included intragastric migration (n=3), gastric leaks (n=2), and gastric fistulas (n=1). The endoscopic treatment of these complications was successful in four of the six patients. Endoscopic band removal was successful in two patients. All gastric leaks were successfully closed via an endoscopic procedure. In two cases (intragastric migration and gastric fistula), endoscopic treatment was not sufficient, and surgery was performed. Conclusions Endoscopic procedures afforded acceptable treatment of band migration and gastric leaks after LAGB. However, the results were poor in patients with gastric fistula.
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Affiliation(s)
- Su Young Kim
- Divison of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyong Yong Oh
- Divison of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jun-Won Chung
- Divison of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yoon Jae Kim
- Divison of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyoung Oh Kim
- Divison of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kwang An Kwon
- Divison of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Dong Kyun Park
- Divison of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyoung Kon Kim
- Department of Family Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Seong Min Kim
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
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11
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Endoscopic Vacuum Therapy (EVT)-a New Concept for Complication Management in Bariatric Surgery. Obes Surg 2018; 27:2499-2505. [PMID: 28695459 DOI: 10.1007/s11695-017-2783-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bariatric surgery is the most efficient therapy for morbid obesity. Staple line and anastomotic leakage are the most feared postoperative complications after Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy (LSG). Traditional treatment options like revisional surgery and endoscopic stent placement are associated with high morbidity and mortality as well as variable success rates. Endoscopic vacuum therapy (EVT) has shown to be a new successful and feasible treatment option for leaks of different etiology after major gastro-esophageal surgery. METHOD We report a case of the EVT principle being applied in a patient with three major leaks located apart from each other within the gastric staple line after LSG for morbid obesity (BMI 62.7). EVT was initiated on postoperative day 8. RESULTS In total, 18 endoscopic interventions were performed in 72 days, the vacuum sponge being replaced endoscopically every 4 days. Hospital length of stay was 106 days. No relevant procedure related complications were observed during the course of therapy and during the follow up. CONCLUSION EVT of postoperative leaks in the upper GI tract has been shown to be feasible and safe. It combines defect closure and effective drainage and allows a periodic inspection of the wound cavity. In case of therapeutic failure, it does not jeopardize surgical repair or stent placement. Even though the techniques and materials used in EVT still vary considerably according to local expertise, EVT has the potential to succeed as a nonsurgical, feasible, safe, and effective treatment option for postoperative leaks in bariatric surgery.
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12
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Pines G, Bar I, Elami A, Sapojnikov S, Hikri O, Ton D, Mosenkis B, Melzer E. Modified Endoscopic Vacuum Therapy for Nonhealing Esophageal Anastomotic Leak: Technique Description and Review of Literature. J Laparoendosc Adv Surg Tech A 2018; 28:33-40. [DOI: 10.1089/lap.2017.0318] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Guy Pines
- Department of Thoracic Surgery, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
| | - Ilan Bar
- Department of Thoracic Surgery, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
| | - Amir Elami
- Department of Thoracic Surgery, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
| | - Shimon Sapojnikov
- Department of Surgery, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
| | - Ofir Hikri
- Department of Thoracic Surgery, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
| | - Dennis Ton
- Department of Invasive Radiology, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
| | - Bruce Mosenkis
- Department of Gastroenterology and Liver Diseases, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
| | - Ehud Melzer
- Department of Gastroenterology and Liver Diseases, Kaplan Medical Center and The Hebrew University School of Medicine, Rehovot, Israel
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13
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Role of Percutaneous Glue Treatment After Persisting Leak After Laparoscopic Sleeve Gastrectomy. Obes Surg 2017; 26:1378-83. [PMID: 26572526 DOI: 10.1007/s11695-015-1959-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Over the years, many treatment modes have been attempted for gastrocutaneous fistula (GCF) after laparoscopic sleeve gastrectomy (LSG). Minimally invasive techniques for GCF treatment include stent placement and radiological percutaneous glue treatment (GT). MATERIAL AND METHOD Ten patients underwent a radiological acrylate mixed with contrast medium GT combined or not with other treatment strategies such as relaparoscopy, ultrasound, or computerized tomography scan (CT scan)-guided drain and endoscopic stent placement. RESULTS Ten patients (mean age 47.1 years, range 64-29) were treated by percutaneous injection of glue after LSG leak. Body mass index (BMI) was 42.2 kg/m(2) ± 6.7 at the time of LSG surgery. Mean time between LSG and leak diagnosis was 12 days (range 4-31 days). GT was only effective when performed after endoscopic stent placement (80 % resolution). With this regimen, five patients required a laparoscopic Roux limb placement. All fistulas eventually healed a mean of 75 days (range 29-293 days) after GCF diagnosis. CONCLUSIONS Percutaneous glue treatment alone does not seem to provide adequate results. Stenting previous to the glue treatment allows for better results.
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Management of leakage and stenosis after sleeve gastrectomy. Surgery 2017; 162:652-661. [DOI: 10.1016/j.surg.2017.04.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/25/2017] [Accepted: 04/26/2017] [Indexed: 12/22/2022]
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15
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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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17
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Transluminal or Percutaneous Endoscopic Drainage and Debridement of Abscesses After Bariatric Surgery: a Case Series. Obes Surg 2016; 25:2190-9. [PMID: 26342480 DOI: 10.1007/s11695-015-1854-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Since redo surgery is associated with a high risk of morbidity and mortality after bariatric surgery in case of leakage, we sought to evaluate whether endoscopic drainage and debridement of collections following bariatric surgery is an efficient step-up approach to the management of these complications. METHODS From 2007 to 2011, we retrospectively studied our cohort of nine cases treated by endoscopic drainage and debridement of abdominal abscesses secondary to postbariatric surgery leaks performed via the transluminal or percutaneous route. RESULTS Three patients were treated by percutaneous endoscopic debridement of abscesses knowing that their leak was already closed by other endoscopic means and that their collection did not improve despite external drain in place. Six patients were treated by transluminal endoscopic drainage to perform necrosectomy as a first-line option or after failure of improvement after endoscopic treatment. The number of sessions required ranged from 1 to 3. Most severe patients had rapid improvement of their hemodynamic and respiratory conditions. In eight of the nine patients, we were able to close the fistula by stent, fistula plugs, or a macroclip. Resolution of collections was seen in seven out of nine patients, but two required further surgery. CONCLUSIONS Endoscopic necrosectomy via the transluminal or percutaneous route is a feasible option in postbariatric surgery patients with necrotic abscesses not adequately managed by the classical combination of percutaneous drainage and stenting. Further wide-scale studies are needed to compare this non-surgical method with surgical necrosectomy in postbariatric surgery patients.
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18
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Eisendrath P, Deviere J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol 2015; 12:701-10. [PMID: 26347162 DOI: 10.1038/nrgastro.2015.151] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Leaks are the most frequent early postoperative complication in the two most popular bariatric procedures, Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy. Multimodal therapy based on self-expandable stent insertion 'to cover' the defect is the most widely documented technique to date with a reported success rate >80%. Additional experimental techniques 'to close' the defect or 'to drain' the paradigestive cavity have been reported with encouraging results. The role of endoscopy in early postoperative bleeding is limited to management of bleeds arising from fresh sutures and the diagnosis of chronic sources of bleeding such as marginal ulcer after RYGB. Post-RYGB stricture is a more delayed complication than leaks and the role of endoscopic dilation as a first-line treatment in this indication is well documented. Ring and band placement are outdated procedures for obesity treatment, but might still be an indication for endoscopic removal, a technique which does not compromise further surgery, if needed.
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Affiliation(s)
- Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Jacques Deviere
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
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19
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Galloro G, Ruggiero S, Russo T, Telesca DA, Musella M, Milone M, Manta R. Staple-line leak after sleve gastrectomy in obese patients: A hot topic in bariatric surgery. World J Gastrointest Endosc 2015; 7:843-846. [PMID: 26240685 PMCID: PMC4515418 DOI: 10.4253/wjge.v7.i9.843] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/08/2015] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
Laparoscopic sleeve gastrectomy is a surgical procedure that is being increasingly performed on obese patients. Among its complications, leaks are the most serious and life threatening. The placement of esophageal, covered, self-expandable metal stents in these cases has been performed by many authors but reports on the outcome of this procedure are limited and the technical aspects are not well defined. Stent migration is the main complication of the procedure and poses a challenge to the surgeon, with a limited number of options. Here we evaluate the technical and clinical outcome of a new, dedicated, self-expanding metal stent, comparing the advantages of this stent to those traditionally used to treat staple-line leak after sleeve gastrectomy. While published data are limited, they seem support the use of this kind of new stent as the best option for the stenting treatment of a staple-line leak after sleeve gastrectomy, over other kinds of stents. Further studies based on larger series are needed to better evaluate patient outcome.
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20
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Galloro G, Ruggiero S, Russo T, Telesca DA, Musella M, Milone M, Manta R. Staple-line leak after sleve gastrectomy in obese patients: A hot topic in bariatric surgery. World J Gastrointest Endosc 2015. [PMID: 26240685 DOI: 10.4253/wjge.v7.i9.843.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Laparoscopic sleeve gastrectomy is a surgical procedure that is being increasingly performed on obese patients. Among its complications, leaks are the most serious and life threatening. The placement of esophageal, covered, self-expandable metal stents in these cases has been performed by many authors but reports on the outcome of this procedure are limited and the technical aspects are not well defined. Stent migration is the main complication of the procedure and poses a challenge to the surgeon, with a limited number of options. Here we evaluate the technical and clinical outcome of a new, dedicated, self-expanding metal stent, comparing the advantages of this stent to those traditionally used to treat staple-line leak after sleeve gastrectomy. While published data are limited, they seem support the use of this kind of new stent as the best option for the stenting treatment of a staple-line leak after sleeve gastrectomy, over other kinds of stents. Further studies based on larger series are needed to better evaluate patient outcome.
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Affiliation(s)
- Giuseppe Galloro
- Giuseppe Galloro, Simona Ruggiero, Teresa Russo, Donato Alessandro Telesca, Department of Clinical Medicine and Surgery, Surgical Digestive Endoscopy Unit, University Federico II - School of Medicine, 80131 Naples, Italy
| | - Simona Ruggiero
- Giuseppe Galloro, Simona Ruggiero, Teresa Russo, Donato Alessandro Telesca, Department of Clinical Medicine and Surgery, Surgical Digestive Endoscopy Unit, University Federico II - School of Medicine, 80131 Naples, Italy
| | - Teresa Russo
- Giuseppe Galloro, Simona Ruggiero, Teresa Russo, Donato Alessandro Telesca, Department of Clinical Medicine and Surgery, Surgical Digestive Endoscopy Unit, University Federico II - School of Medicine, 80131 Naples, Italy
| | - Donato Alessandro Telesca
- Giuseppe Galloro, Simona Ruggiero, Teresa Russo, Donato Alessandro Telesca, Department of Clinical Medicine and Surgery, Surgical Digestive Endoscopy Unit, University Federico II - School of Medicine, 80131 Naples, Italy
| | - Mario Musella
- Giuseppe Galloro, Simona Ruggiero, Teresa Russo, Donato Alessandro Telesca, Department of Clinical Medicine and Surgery, Surgical Digestive Endoscopy Unit, University Federico II - School of Medicine, 80131 Naples, Italy
| | - Marco Milone
- Giuseppe Galloro, Simona Ruggiero, Teresa Russo, Donato Alessandro Telesca, Department of Clinical Medicine and Surgery, Surgical Digestive Endoscopy Unit, University Federico II - School of Medicine, 80131 Naples, Italy
| | - Raffaele Manta
- Giuseppe Galloro, Simona Ruggiero, Teresa Russo, Donato Alessandro Telesca, Department of Clinical Medicine and Surgery, Surgical Digestive Endoscopy Unit, University Federico II - School of Medicine, 80131 Naples, Italy
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Odemis B, Beyazit Y, Torun S, Kayacetin E. Endoscopic closure of gastrocutaneous fistula with an AMPLATZER(TM) septal occluder device. Therap Adv Gastroenterol 2015; 8:239-42. [PMID: 26136841 PMCID: PMC4480572 DOI: 10.1177/1756283x15578609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Bulent Odemis
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Yavuz Beyazit
- Department of Gastroenterology, Canakkale State Hospital, Canakkale, 17100, Turkey
| | - Serkan Torun
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Ertugrul Kayacetin
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
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Liu SYW, Wong SKH, Ng EKW. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract 2014; 9:214-9. [PMID: 25534492 DOI: 10.1016/j.orcp.2014.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/15/2014] [Accepted: 11/28/2014] [Indexed: 11/26/2022]
Abstract
The management of gastric leak after laparoscopic sleeve gastrectomy (LSG) can be complex and challenging. Whilst operative interventions are mostly complicated and reserved for unstable or refractory cases, endoscopic self-expandable metal stenting (SEMS) is increasingly preferred as a safer treatment option. Yet, SEMS carries the problems of frequent stent migration and inconsistent healing as ordinary SEMS is designed mainly for stenotic disease. We hereby present two cases of early and chronic post-LSG leakage that were respectively failed to be treated by surgery and ordinary SEMS but were successfully managed by a dedicated extra-long oesophago-gastro-duodenal stent. In oesophago-gastro-duodenal stenting, the characteristics of extra-long stent length allow total gastric exclusion between the mid-oesophagus and the first part of duodenum to prevent stent migration and to equalise high pressure gradient within the gastric sleeve to promote fistula healing.
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Affiliation(s)
- Shirley Yuk-Wah Liu
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Simon Kin-Hung Wong
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Enders Kwok-Wai Ng
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China.
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Does somatostatin-14 have an impact on gastric fistula after laparoscopic sleeve gastrectomy? Obes Surg 2014; 25:377-80. [PMID: 25381116 DOI: 10.1007/s11695-014-1483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The main complications following laparoscopic sleeve gastrectomy (LSG) is gastric fistula (GF). Gastric fistula is a rare but serious complication (affecting 2 % of LSGs). Somatostatin-14 and its analogs are mainly used in the prevention and curative treatment of digestive fistulas. These compounds inhibit secretions in the pancreas, stomach, and small intestine. Treatment with somatostatin-14 increases the spontaneous closure rate and reduces the closure time of postoperative digestive fistulas. However, the impact of somatostatin-14 on GF after LSG has not been studied. We report on a prospective, non-randomized, single-center, case-matched study of patients receiving somatostatin-14 after a post-LSG GF was discovered. Our results suggest that use of somatostatin-14 is associated with a shorter length of hospital stay and (perhaps) a shorter treatment period.
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24
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Kotzampassi K, Eleftheriadis E. Tissue sealants in endoscopic applications for anastomotic leakage during a 25-year period. Surgery 2014; 157:79-86. [PMID: 25444220 DOI: 10.1016/j.surg.2014.06.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leakage after gastrointestinal operation is a complication difficult to manage because conservative therapy and/or reoperation may be unsuccessful and carry the risk of increased morbidity and mortality. The endoscopic use of tissue sealants appears to be a promising alternative to avoid operation. METHOD We present conclusively our 25-year experience with tissue sealing in a series of 63 patients referred after gastrointestinal anastomosis leakage; 48 of the upper and 15 of the lower gastrointestinal tract, experiencing a drainage volume ranging 50-2,400 mL. RESULTS Tissue glue was applied orally in 37, anally in 10, through the fistula tract in 8, and through a combination of approximation routes in another 8 cases. Biological glue (fibrin) was used in 47, cyanoacrylate in 8, and both glue types in another 8 patients. The total volume of fibrin applied was 2-36 mL, in a median of four sessions, 0.5-4 mL for cyanoacrylate, in a median of two sessions, and, whenever a combination of glues was used, a volume of 12-40 mL of fibrin plus 1-4 mL of cyanoacrylate, in a median of nine sessions. The median hospital stay after initiation of gluing was 14 days (range 8-32). The clinical and technical success rate was 96.8% (61 of 63 patients). CONCLUSION Tissue glue appears to be a valuable clinical tool that would prevent further operative interventions and the associated morbidity and mortality after a gastrointestinal anastomosis dehiscence. However, it must be borne in mind that repeated sessions and large volumes of sealants are necessary in many cases.
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Affiliation(s)
- Katerina Kotzampassi
- Department of Surgery, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymios Eleftheriadis
- Department of Surgery, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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25
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Baretta G, Campos J, Correia S, Alhinho H, Marchesini JB, Lima JH, Neto MG. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc 2014; 29:1714-20. [PMID: 25294547 DOI: 10.1007/s00464-014-3869-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 09/04/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Gastric fistula after bariatric surgery has high morbi-mortality, and treatment is a challenge due to persistent abscess and/or distal stenosis. The present study evaluated the efficacy and safety of stricturotomy/internal drainage, a novel endoscopic procedure that can avoid re-operation and allow early oral feeding. METHODS This prospective, non-randomized study, with no control or sham group, included 27 patients (74.07% were female), approved by the local IRB, who underwent the following bariatric surgeries: Roux-en-Y gastric bypass (RYGB; n = 14, 51.85%), laparoscopic sleeve gastrectomy (LSG; n = 9, 33.33%) and duodenal switch (DS; n = 4, 14.81%). The patients presented with gastric fistulas which were treated by internal drainage/stricturotomy. The mean patient age was 42.67 years, and the mean pre-operative BMI was 40.69 kg/m(2). Balloon dilation was performed if distal stenosis and/or axis deviation was present. The first endoscopic procedure was applied on the 15th day after RYGB and the 30th day after LSG and DS. RESULTS All patients presented with His angle fistula. Eight patients (57.1%) had stenosis of the anastomosis after RYGB and were treated with balloon dilatation (20 mm). The patients submitted to LSG and DS had stenosis at the angularis incisure and were treated with achalasia balloon dilation (30 mm). The number of endoscopic sessions for stricturotomy ranged from 1 to 6. Two patients experienced bleeding after dilation, and one had perforation. The mean time to achieve fistula closure was 18.11 days (range, 1-72 days) without mortality. All the fistulas closed. CONCLUSIONS This novel endoscopic procedure is safe, feasible, and effective, avoiding re-operation, allowing early oral feeding and discharge.
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Mathus-Vliegen EMH. The cooperation between endoscopists and surgeons in treating complications of bariatric surgery. Best Pract Res Clin Gastroenterol 2014; 28:703-25. [PMID: 25194185 DOI: 10.1016/j.bpg.2014.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/18/2014] [Accepted: 07/05/2014] [Indexed: 02/09/2023]
Abstract
The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.
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Affiliation(s)
- E M H Mathus-Vliegen
- Academic Medical Centre, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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27
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Chouillard E, Chahine E, Schoucair N, Younan A, Jarallah MA, Fajardy A, Vitte RL, Biagini J. Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post–sleeve gastrectomy fistula. Surg Endosc 2014; 28:1954-60. [DOI: 10.1007/s00464-014-3424-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 01/01/2014] [Indexed: 12/19/2022]
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The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks. Surg Obes Relat Dis 2014; 10:106-10. [DOI: 10.1016/j.soard.2013.08.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 07/07/2013] [Accepted: 08/19/2013] [Indexed: 12/31/2022]
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Ben Yaacov A, Sadot E, Ben David M, Wasserberg N, Keidar A. Laparoscopic Total Gastrectomy with Roux-Y Esophagojejunostomy for Chronic Gastric Fistula After Laparoscopic Sleeve Gastrectomy. Obes Surg 2013; 24:425-9. [DOI: 10.1007/s11695-013-1162-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
Bariatric surgery is the most effective treatment for the medical comorbidities associated with morbid obesity. Though uncommon, staple line or anastomotic leaks after bariatric surgery are highly morbid events and challenging to treat. In selected patients without severe sepsis or distant pollution, endoscopic transluminal peritoneal drainage may provide source control. For leaks within 3 days of surgery, endoscopic stenting does not appear to speed closure but does permit oral nutrition. In uncomplicated situations, the risk of migration and resulting complications of enteric stents appear to overshadow the benefits. Initial treatment failures and leaks presenting more than 48 hours after surgery respond to enteric diversion by endoscopic stenting. Occlusion of the leak by injection of fibrin glue also shows promise; however, these case series are limited to a small number of patients. Endoclips may work best to occlude leaks and close fistulas if the epithelium is debrided. As suturing technology improves, direct internal closure of fistulas may prove feasible. Therapeutic endoscopy offers several technologies that can assist in the closure of early leaks and that are essential to the treatment of late leaks and fistulas after bariatric surgery.
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Bhat YM, Banerjee S, Barth BA, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Rodriguez SA. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc 2013; 78:209-15. [PMID: 23867370 DOI: 10.1016/j.gie.2013.04.166] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 12/11/2022]
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Minimally invasive treatment of gastric leak after sleeve gastrectomy. Radiol Med 2013; 118:962-70. [DOI: 10.1007/s11547-013-0938-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 09/06/2012] [Indexed: 12/19/2022]
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Acute complications after laparoscopic bariatric procedures: update for the general surgeon. Langenbecks Arch Surg 2013; 398:669-86. [DOI: 10.1007/s00423-013-1077-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 03/05/2013] [Indexed: 12/24/2022]
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El Mourad H, Himpens J, Verhofstadt J. Stent treatment for fistula after obesity surgery: results in 47 consecutive patients. Surg Endosc 2012; 27:808-16. [PMID: 23052499 DOI: 10.1007/s00464-012-2517-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 07/03/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery. METHODS We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications. RESULTS There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment. CONCLUSIONS Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.
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Affiliation(s)
- Haicam El Mourad
- Obesity Surgery Department, AZ St. Blasius Hospital, 50 Kroonveldlaan, 9200 Dendermonde, Belgium.
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Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 2012; 27:240-5. [PMID: 22752283 DOI: 10.1007/s00464-012-2426-x] [Citation(s) in RCA: 266] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 05/30/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. METHODS Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. RESULTS Among the 2,834 patients who underwent LSG, 44 (1.5%) with gastric leaks were identified. Of these 44 patients, 30 (68%) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m(2). Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3%) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20%), intermediately (3-14 days) in 32 cases (73%), and late (>14 days) in three cases (7%). For 38 patients (86%), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84%), 11 (50%), and 9 (60%) of these patients. Reoperation was performed for 27 of the patients (61%). Other treatment methods included percutaneous drainage (n = 28, 63.6%), endoscopic placement of stents (n = 11, 25%), clips (n = 1, 2.3%), and fibrin glue (n = 1, 2.3%). In 33 of the patients (75%), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14% (4/2,834). CONCLUSION Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.
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Lorenzo-Rivero S, Rosen PD, Moore RA, Stanley JD. Closure of Gastrocutaneous Fistula Using Autologous Blood Product Sealant. Am Surg 2012. [DOI: 10.1177/000313481207800604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shauna Lorenzo-Rivero
- Department of Surgery University of Tennessee College of Medicine Chattanooga Chattanooga, Tennessee
| | - Philip D. Rosen
- Department of Surgery University of Tennessee College of Medicine Chattanooga Chattanooga, Tennessee
| | - Richard A. Moore
- Department of Surgery University of Tennessee College of Medicine Chattanooga Chattanooga, Tennessee
| | - J. Daniel Stanley
- Department of Surgery University of Tennessee College of Medicine Chattanooga Chattanooga, Tennessee
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Kim HH, Park SJ, Park MI, Moon W. Endoscopic hole and clipping technique: a novel technique for closing the wide orifice of a postoperative fistula. Gastrointest Endosc 2012; 75:1250-2. [PMID: 22459662 DOI: 10.1016/j.gie.2012.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 02/03/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic clipping for closing a fistula created by surgery is often difficult because of the combination of a wide orifice and fibrosis. Creating holes for prongs of a clip may constitute a new endoscopic clipping technique for closing the wide orifice of a fistula. OBJECTIVE To assess the feasibility of performing the endoscopic hole and clipping technique (EHCT). DESIGN Experimental pilot study. SETTING Tertiary-care referral center. PATIENT This study involved 1 patient who underwent EHCT. INTERVENTIONS EHCT was performed. MAIN OUTCOME MEASUREMENTS Technical success and procedural complications of EHCT. RESULTS Immediately after the procedure, drainage decreased dramatically and finally decreased to 0 mL/d. There was no evidence of a leak on fluoroscopic examination, and upon 4-month follow-up, we found that no symptoms had developed in the patient. LIMITATIONS Single-patient pilot study. CONCLUSIONS EHCT is very simple and efficient. EHCT can be applied as a means of closing the orifice of a postoperative fistula that is not easily managed by simple endoscopic clipping.
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Affiliation(s)
- Hyung Hun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.
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Abstract
Obesity and its associated conditions, including type 2 diabetes and cardiovascular disease, have reached epidemic proportions. Gastrointestinal weight loss surgery (GIWLS) shows the most promise in achieving significant and sustained weight loss and diabetes resolution. However, a large mismatch exists between the magnitude of the obesity epidemic and the number of surgical procedures performed to produce a significant shift in the distribution of obesity on a population level. This mismatch is fueled by high surgical costs, morbidity and mortality associated with surgical interventions, and the fact that the greatest public health burden of obesity comes from those around the center of the population body mass index distribution with mild to moderate obesity, rather than those at the distribution tail with severe obesity that GIWLS targets. New endoscopic methods, capitalizing on advances in our understanding of the physiological mechanisms by which GIWLS works, are developing to provide viable alternatives in the treatment of bariatric surgical complications, and for the primary treatment of obesity. These methods may have the added advantage of reduced invasiveness, reversibility, cost-effectiveness, and applicability to a larger segment of the population with moderate obesity.
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Affiliation(s)
- Barham K. Abu Dayyeh
- Gastrointestinal Unit, Massachusetts General Hospital, and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Christopher C. Thompson
- Assistant Professor of Medicine, Harvard Medical School, and Director, Developmental and Bariatric Endoscopy, Gastroenterology Division, Brigham and Women’s Hospital, 75 Francis Street, Thorn 14, Boston, MA 02115, USA
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Endoscopic management of gastrogastric fistulae does not increase complications at bariatric revision surgery. J Gastrointest Surg 2011; 15:1736-42. [PMID: 21479671 DOI: 10.1007/s11605-011-1503-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 03/23/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastrogastric fistula (GGF) is a challenging complication of primary obesity surgery that often leads to revision surgery. The impact of prior endoscopic intervention on subsequent surgical revisional outcomes remains unknown. We present the largest series of Roux-en-Y gastric bypass GGF with subsequent surgical revision of fistulae to date. METHODS A database of bariatric surgical revisions performed at a single institution was collected. The cohort was divided between patients with and without attempted endoscopic fistula closure prior to surgical revision. Thirty-day morbidity and mortality was the primary outcome. RESULTS Thirty-five cases of revision were performed for GGF. Of the 35 cases, 22 patients had attempted endoscopic closure prior to surgical revision while 13 patients went directly to surgical revision. In the endoscopy group, two minor complications and seven major complications occurred (total 9 of 22; 40.9%). In the surgery only group, three minor complications and three major complications occurred (total 6 of 13; 46.1%). No deaths occurred. CONCLUSION Prior attempts at endoscopic fistula closure do not lead to increased surgical complications at the time of surgical revision.
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Yimcharoen P, Heneghan HM, Tariq N, Brethauer SA, Kroh M, Chand B. Endoscopic stent management of leaks and anastomotic strictures after foregut surgery. Surg Obes Relat Dis 2011; 7:628-36. [PMID: 21798816 DOI: 10.1016/j.soard.2011.03.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 02/01/2011] [Accepted: 03/23/2011] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anastomotic complications after upper gastrointestinal surgery present an arduous therapeutic challenge. Avoiding revisional surgery is desirable and might be possible with the advent of endoscopically placed stents. We reviewed our experience with endoscopic stent management of anastomotic complications after esophagogastric surgery. METHODS A prospectively maintained database at our surgical endoscopy unit was reviewed to identify patients who had undergone endoscopic stent placement after various foregut procedures. Data were obtained on patient demographics, primary surgical and endoscopic procedures, and outcome. RESULTS From January 2007 to August 2010, 18 patients (12 women, mean age 51 ± 15 yr) underwent endoscopic stent placement for anastomotic complications; 14 were bariatric patients. A total of 31 stents (21 covered metal, 5 salivary, and 5 silicone-coated polyester) were used to treat anastomotic leaks (n = 13), strictures (n = 3), and fistulas (n = 2). Symptomatic improvement occurred in all but 2 patients (89%), and early oral intake was initiated in 11 (61%). Stent treatment was successful in definitively managing the anastomotic complication in 13 (72%) of the 18 patients. Five patients required additional surgical or endoscopic intervention. Stent migration occurred in 4 cases and was amenable to endoscopic management. Two patients died, with both deaths unrelated to stent placement. CONCLUSION Endoscopic stent management of anastomotic complications after foregut surgery is effective in resolving symptoms, expediting enteral nutrition, and particularly successful for treating anastomotic leaks. In the absence of stents specifically designed for surgically altered gastrointestinal anatomy, some factors that might reduce the risk of stent migration include appropriate stent selection, anchoring the stent proximally, and regular surveillance after placement.
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Affiliation(s)
- Panot Yimcharoen
- Bariatric and Metabolic Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Keith JN. Endoscopic management of common bariatric surgical complications. Gastrointest Endosc Clin N Am 2011; 21:275-85. [PMID: 21569979 DOI: 10.1016/j.giec.2011.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation. Endoscopists caring for these patients should become familiar with post-bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal/extra-luminal findings, and endoscopic management of common bariatric complications; this review addresses these issues. This review will discuss common presenting symptoms, luminal as well as extra-luminal findings and endoscopic management of common bariatric complications.
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Affiliation(s)
- Jeanette N Keith
- Section of Gastroenterology, State University of New York, University of Buffalo, and Buffalo General Hospital, 100 High Street, Buffalo, NY 14203, USA.
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Abstract
Sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, the number of surgeons using it has grown in recent years. The patients who present fistulas after surgery often undergo a harrowing postoperative period as well as increased morbidity and mortality. Our aim was to assess the incidence, causes, diagnosis, management, and prevention of leaks after sleeve gastrectomy.
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Leaks after sleeve gastrectomy are associated with smaller bougies: prevention and treatment strategies. Surg Laparosc Endosc Percutan Tech 2010; 20:166-9. [PMID: 20551815 DOI: 10.1097/sle.0b013e3181e3d12b] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bhardwaj A, Cooney RN, Wehrman A, Rogers AM, Mathew A. Endoscopic repair of small symptomatic gastrogastric fistulas after gastric bypass surgery: a single center experience. Obes Surg 2010; 20:1090-5. [PMID: 20440578 DOI: 10.1007/s11695-010-0180-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Gastrogastric fistula (GGF) is a known complication of gastric bypass surgery. Revisional surgery for GGF repair can be technically challenging. We describe our experience with endoscopic repair of small GGFs. A retrospective review was performed to identify patients in whom symptomatic GGF was repaired endoscopically at our institution between September 2004 and September 2008. At endoscopy, the fistulous margins were debrided using cold biopsy forceps or ablated using Argon Plasma Coagulation (APC). The fistula was then repaired with endoclips. Status of GGF repair was assessed intra-operatively, at 2 weeks by upper gastrointestinal (UGI) series, and at regular follow-up thereafter. GGF repair was attempted in eight female patients (mean age = 47 years). The average time interval between gastric bypass surgery and GGF presentation was 81 months. The presenting symptoms included nausea, vomiting, abdominal pain, and weight regain. The average duration of endoscopic procedure was 55 min. All GGFs were small (<20 mm). Endoscopic repair of GGF was successful intra-operatively in all patients. Two patients had failure of GGF repair at 2 weeks. Other two patients experienced recurrent symptoms after several weeks and had a delayed failure of GGF repair diagnosed by UGI series. Endoscopic repair has remained successful in four patients at 8-46 months follow-up. Endoscopic repair of small GGFs using endoclips is feasible. It must be considered as an option for management of small GGFs, given its safety, and ease of performance compared to revisional surgery.
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Affiliation(s)
- Atul Bhardwaj
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, H034, P.O. Box 850, Hershey, PA 17033-0850, USA.
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Endoscopic Management of Drain Inclusion in the Gastric Pouch after Gastrojejunal Leakage after Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity (LRYGBP). DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2010; 2010:891345. [PMID: 20634928 PMCID: PMC2903945 DOI: 10.1155/2010/891345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 05/01/2010] [Indexed: 01/12/2023]
Abstract
Background. Drain inclusion inside the gastric pouch is rare and can represent an important source of morbidity and mortality associated with laparocopic Roux-en-Y gastric bypass (LRYGBP). These leaks can become chronic and challenging. Surgical options are often unsuccessful. We present the endoscopic management of four patients with drain inclusion.
Patients. All four obese morbidly patients underwent LRYGBP and presented a gastro-jejunal fistula after acute anastomotic leakage. During follow-up endoscopy the drain was found inside the gastric pouch. It was moved into the abdominal cavity. Fistula debit reduced significantly and closed. Results. Gastric leak closure in less than 24 hours was achieved in all, with complete resolution of symptoms. These patients benefited exclusively from endoscopic treatment. Conclusions. Endoscopy is useful and technically feasible in chronic fistulas. This procedure is a less invasive alternative to traditional surgical revision. Other therapeutic strategies can be used such as clips and fibrin glue. Drains should not be placed in contact with the anastomosis or stapled lines. Drain inclusion must be suspected when fistula debit suddenly arises. If so, endoscopy is indicated for diagnostic accuracy. Under endoscopy vision, the drain is gently removed from the gastric reservoir leading to sudden and complete resolution of the fistula.
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Spaun GO, Martinec DV, Kennedy TJ, Swanström LL. Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos). Gastrointest Endosc 2010; 71:606-11. [PMID: 20018279 DOI: 10.1016/j.gie.2009.09.044] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 09/25/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight. OBJECTIVE The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy. DESIGN A feasibility and outcome study following institutional review board protocol. SETTING Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon. INTERVENTIONS A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF. PATIENTS Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm). RESULTS Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening. CONCLUSION It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.
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Affiliation(s)
- Georg O Spaun
- Minimally Invasive Surgery Program, Legacy Health System, Portland, Oregon 97210, USA.
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Papavramidis TS, Pliakos I, Charpidou D, Petalotis G, Kollaras P, Sapalidis K, Kesisoglou I, Papavramidis ST. Management of an extrasphincteric fistula in an HIV-positive patient by using fibrin glue: a case report with tips and tricks. BMC Gastroenterol 2010; 10:18. [PMID: 20152052 PMCID: PMC2829488 DOI: 10.1186/1471-230x-10-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2009] [Accepted: 02/14/2010] [Indexed: 12/12/2022] Open
Abstract
Background Individuals with impaired immunity are at higher risk of perianal diseases. Concerning complex anal fistulas impaired healing and complication rates are also higher. Definitive treatment of a fistula aims controlling the purulent discharge and prevents its recurrence. It depends mainly on the trajectory of the fistula and the underlying disease. We present a case of a HIV-positive patient with a complex extrasphincteric anal fistula who was treated successfully with fibrin glue application. We further, discuss tips and tricks when applying fibrin glue as plugging material in complex anal fistulas. Case presentation A sixty-one-year-old HIV-positive male referred to us for warts and extrasphincteric fistula. Because of the patients' immunological status, we opted against surgery and recommended fibrin glue plugging. The patient was discharged the same day. A follow-up examination was performed 5 days after the initial fibrin glue application showing that the fistula canal was obstructed. Three months and a year post-intervention the fistula tract remains closed. Conclusion The best treatment for a disease gives at least the same result with the other treatments with minimised risk for the life of the patient and minimal application effort. Conservative closure of fistula with fibrin plugging is simple, safe and with less morbidity than surgery. Our patient was successfully treated without endangering his life despite his precarious medical state. Not everybody believes in the effectiveness of fibrin glue application, however we consider this solution in cases of complex fistulas at least as primary procedure in special populations such as the immunosupressed.
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Affiliation(s)
- Theodossis S Papavramidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Endoscopy after bariatric surgery (with videos). Gastrointest Endosc 2009; 70:1161-6. [PMID: 19647249 DOI: 10.1016/j.gie.2009.03.1168] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Accepted: 03/22/2009] [Indexed: 02/08/2023]
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49
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Successful Management of Refractory Staple Line Leakage at the Esophagogastric Junction After a Sleeve Gastrectomy Using the HANAROSTENT. Obes Surg 2009; 20:530-4. [DOI: 10.1007/s11695-009-9976-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2009] [Accepted: 09/01/2009] [Indexed: 01/28/2023]
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50
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Cutaneous Fistula from the Gastric Remnant Resulting from a Chronic Suture-associated Biofilm Infection. Obes Surg 2009; 20:251-6. [DOI: 10.1007/s11695-009-9921-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 06/30/2009] [Indexed: 10/20/2022]
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