Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

Endoscopic therapies for bariatric surgery complications

PURPOSE OF REVIEW

The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications.

RECENT FINDINGS

The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB.

SUMMARY

Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.

Endoscopic Management of Bariatric Surgery Complications: Fistulas, Leaks, and Ulcers

Bariatric surgery is a safe and effective treatment option for patients with obesity and obesity-related comorbidities, with Roux-en-Y gastric bypass and sleeve gastrectomy being the two most common procedures. Despite the success of these interventions, adverse events are not uncommon. Endoscopic management has become first-line therapy when complications occur, and the armamentarium of devices and techniques continues to grow. This article focuses on the management of fistulas, leaks, and ulcers and also focuses on the etiology and endoscopic management strategy of each complication.

Primary Repair of Gastrobronchial Fistula Presenting 12 Years Post Uncomplicated Laparoscopic Sleeve Gastrectomy

Background

Obesity is an alarmingly increasing global public health issue. Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery owing to its simplicity, effectiveness, and low complication rates. The complications can be classified as early or late, with fistula formation being one of the most severe complications. Here, we report a rare gastrobronchial fistula (GBF) that presented 12 years post LSG.

Case Presentation

A 34-year-old woman who underwent LSG in 2011 was referred to our institution. The patient complained of recurrent upper respiratory tract infections, nausea, and vomiting. Abdominal computed tomography (CT) with oral contrast showed abnormal fistulous communication between the fundus and left lung. Conservative management was initiated but failed multiple times. After counseling the patient on the surgical options, she underwent fistula removal and primary repair of the fundus with a healthy omental wrap and an omental diaphragmatic flap. She tolerated the procedure well, recovered uneventfully, and was discharged on postoperative day 7.

Conclusion

GBF diagnosis is challenging. Imaging studies, such as CT and radiography with contrast and endoluminal diagnosis with esophagogastroduodenoscopy (EGD), bronchoscopy, and bronchial secretion analysis, aid in the diagnosis. GBF management requires a multidisciplinary team. Patients should be initially offered conservative management with the understanding that reoperation would be the only option if failure is seen for 3 months.

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis

BACKGROUND

Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure.

METHODS

A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines.

RESULTS

Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%.

CONCLUSION

Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

The Role of Endoscopy in the Management of Adolescent Bariatric Patients: A Primer For Pediatric Gastroenterologists

PURPOSE OF REVIEW

The prevalence of childhood and adolescent obesity in the United States has reached alarming levels, necessitating effective interventions such as bariatric surgery. This article reviews the current state of bariatric surgery in the adolescent population, highlighting the common complications encountered in post-bariatric patients. Furthermore, it outlines the pivotal role of endoscopy in both the prevention and management of these bariatric complications.

RECENT FINDINGS

Though only a minority of eligible adolescent patients undergo bariatric surgery the number of cases continues to increase. Sleeve gastrectomy has emerged as the preferred type of surgery, with the best balance of safety and efficacy. However, only a small number of pediatric surgeons have additional bariatric training and a number of technical aspects of the surgery itself impact the risk for post-surgical complications. Gastric sleeve stenosis, anastomotic leaks and gastroesophageal reflux are the most common of these complications. Ability to perform dilation of sleeve stenosis, closure of anastomotic leaks and evaluation of reflux are critical tools in the endoscopic toolbox necessary for the management of these complicated patients. Bariatric surgery remains the most effective treatment available for management of morbid obesity in adolescents but has significant associated complications. Pediatric gastroenterologists must be familiar in the endoscopic management of these complications and are crucial in creating a high functioning adolescent bariatric program.