Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results

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.

Clinical Management of Major Postoperative Bleeding After Bariatric Surgery

INTRODUCTION

Major postoperative bleeding (mPOB) is the most common complication after bariatric surgery. Its intesity varies from self-limiting to life-threatening situations. Comprehensive decision-making and treatment strategies are mandatory but not established yet.

METHODS

We retrospectively analyzied our prospectively collected database of our bariatric patients during 2012-2022. The primary study endpoint was major postoperative bleeding (mPOB) defined as hemoglobin drop > 2 g/dl or clinically relevant bleeding requiring intervention (transfusion, endoscopy or surgery). Secondary endpoints were overall complications according to Clavien-Dindo-Classification and comprehensive-complication-index (CCI).

RESULTS

We identified 1017 patients, of whom 667 underwent gastric bypass (GB) and 350 sleeve gastrectomy (SG). Major postoperative bleeding occured in 39 patients (total 3.8%; 5.1% after GB and 2.3% after SG). Patients with mPOB were more often diagnosed with type 2 diabetes (p = 0.039), chronic kidney failure (p = 0.013) or received antiplatelet drug treatment (p = 0.003). The interval from detection to intervention within 24 h was 92.1% (35/39). Blood transfusions were necessary in 20/39 cases (total 51.3%; 45.2% after GB and 75% after SG; p = 0.046). Luminal bleeding only occured after GB (19/31; 61.3%), while all mPOB after SG were intraabdominal (p = 0.002). Reoperations were performed in 21/39 (total 53.8%; 48.4% after GB and 75% after SG; p = 0.067). CCI in patients with mPOB was 34.7 overall, with 31.2 after GB and 47.9 after SG (p = 0.005).

CONCLUSION

The clinical appearance of mPOB depends on the type of surgery with severe bleedings after SG. We suggest a surgery first approach for mPOB after SG and an endoscopy first approach after GB.

Endoscopic management of postoperative bleeding

Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.

Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks

Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.

Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review

Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.

Early Bleeding After Laparoscopic Roux-en-Y Gastric Bypass: Incidence, Risk Factors, and Management - a 21-Year Experience

Purpose

Morbidity and mortality associated with bariatric surgery are considered low. The aim of this study is to assess the incidence, clinical presentation, risk factors, and management of early postoperative bleeding (POB) after laparoscopic Roux-en-Y gastric by-pass (RYGB).

Materials and Methods

Retrospective analysis of prospectively collected data of consecutive patients who underwent RYGB in 2 expert bariatric centers between January 1999 and April 2020, with a common bariatric surgeon.

Results

A total of 2639 patients underwent RYGB and were included in the study. POB occurred in 72 patients (2.7%). Intraluminal bleeding (ILB) was present in 52 (72%) patients and extra-luminal bleeding (ELB) in 20 (28%) patients. POB took place within the first 3 postoperative days in 79% of patients. The most frequent symptom was tachycardia (63%). Abdominal pain was more regularly seen with ILB, compared to ELB (50% vs. 20%, respectively, p = 0.02). Male sex was an independent risk factor of POB on multivariate analysis (p < 0.01). LOS was significantly longer in patients who developed POB (8.3 vs. 3.8 days, p < 0.01). Management was conservative for most cases (68%). Eighteen patients with ILB (35%) and 5 patients with ELB (25%) required reoperation. One patient died from multiorgan failure after staple-line dehiscence of the excluded stomach (mortality 0.04%).

Conclusion

The incidence of POB is low, yet it is the most frequent postoperative complication after RYGB. Most POB can be managed conservatively while surgical treatment is required for patients with hemodynamic instability or signs of intestinal obstruction due to an intraluminal clot.

Graphical abstract

Aspirin Use as a Risk Factor for Marginal Ulceration in Roux-en-Y Gastric Bypass Patients: A Meta-Analysis of 24,770 Patients

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a recognized, safe bariatric procedure with minimal complications. Marginal ulceration, however, remains a challenging problem with an incidence of 8-12%. While chronic NSAID use is an established risk factor for ulcer formation, aspirin use itself as a cause for marginal ulceration is still unclear. We aim to compare the rates of marginal ulceration in RYGB with and without aspirin use.

METHODS

PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were searched for articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale. Meta-analysis was conducted using a fixed-effect model.

RESULTS

From 5324 studies screened, we included 3 studies. Two studies had a low risk of bias, and the other one presented a high risk of bias on the Newcastle-Ottawa Scale. We included 24,770 patients, 1911 with aspirin use and 22,859 without aspirin use. After the meta-analysis, patients who used aspirin had a significantly higher marginal ulceration rate than those who did not (OR = 1.33 [95% CI 1.08 to 1.63], P < .002; I² = 39%).

CONCLUSIONS

Aspirin use is associated with increased rates of marginal ulceration after RYGB.

Roux-en-Y Versus One Anastomosis Gastric Bypass as Redo-Operations Following Sleeve Gastrectomy: A Retrospective Study

BACKGROUND

Aim of this study was to improve knowledge about the best conversional bariatric procedure following sleeve gastrectomy (SG).

METHODS

Data of conversional Roux-en-Y gastric bypass (RYGB) and of one anastomosis gastric bypass (OAGB) after SG were collected prospectively and analyzed retrospectively. Weight loss parameters, gastroesophageal reflux disease (GERD) and comorbidities outcomes were recorded.

RESULTS

Total of 123 patients (90 female, mean age 44 ± 0.9 years, mean body mass index (BMI) 42 ± 0.8 kg/m²) had either RYGB (n = 68) or OAGB (n = 55). Perioperative mortality was zero. Mean surgery time was significantly shorter for OAGB (168 ± 7.2 vs. 201 ± 6.8 min). Perioperative complication rates were not significantly (ns) different between RYGB and OAGB. Total body weight loss (TBWL) in RYGB and OAGB was 18 ± 2.2% and 18 ± 1.9% (12 months) and 18 ± 3.0% and 23 ± 2.6% (24 months; ns), respectively. Length of (individualized) biliopancreatic limb (BPL) correlated significantly with weight loss. Remission rates after 12 months of RYGB and OAGB for arterial hypertension (aHt) were 89% and 92%, for obstructive sleep apnea (OSAS) 56% and 82%, for Type 2 diabetes mellitus (T2DM) 100% and 92%, for osteoarthritis 64% and 85% and for GERD 89% versus 87% (ns), respectively. Nutritional deficiencies were comparable in RYGB (n = 11) and OAGB (n = 14) group (ns).

CONCLUSION

Both RYGB and OAGB are effective conversional procedures after SG, leading to comparable TBWL, BMI-loss and high remission rates of comorbidities including GERD. Significantly shorter operation times were in favor of OAGB. BPL, which was longer in OAGB was significantly related to higher %TBWL and %BMI-loss compared to RYGB.

Endoscopic vacuum therapy in salvage and standalone treatment of gastric leaks after bariatric surgery

Introduction

Gastric leaks constitute some of the most severe complications after obesity surgery. Resulting peritonitis can lead to inflammatory changes of the stomach wall and might necessitate drainage. The inflammatory changes make gastric leak treatment difficult. A common endoscopic approach of using stents causes the problem of inadequate leak sealing and the need for an external drainage. Based on promising results using endoscopic vacuum therapy (EVT) for esophageal leaks, we implemented this concept for gastric leak treatment after bariatric surgery (Ahrens et al., Endoscopy 42(9):693–698, 2010; Schniewind et al., Surg Endosc 27(10):3883–3890, 2013).

Methods

We retrospectively analyzed data of 31 gastric leaks after bariatric surgery. For leak therapy management, we used revisional laparoscopy with suturing and drainage. EVT was added for persistent leaks in sixteen cases and was used in four cases as standalone therapy.

Results

Twenty-one gastric leaks occurred in 521 sleeve gastrectomies (leakage rate 4.0%), 9 in 441 Roux-en-Y gastric bypasses (leakage rate 2.3%), and 1 in 12 mini-bypasses. Eleven of these gastric leaks were detected within 2 days after bariatric surgery and successfully treated by revision surgery. Sixteen gastric leaks, re-operated later than 2 days, remained after revision surgery, and EVT was added. Without revision surgery, we performed EVT as standalone therapy in 4 patients with late gastric leaks. The EVT healing rate was 90% (18 of 20). In 2 patients with a late gastric leak in sleeve gastrectomy, neither revisional surgery, EVT, nor stent therapy was successful. EVT patients showed no complications related to EVT during follow-up.

Conclusion

EVT is highly beneficial in cases of gastric leaks in obesity surgery where local peritonitis is present. Revisional surgery was unsuccessful later than 2 days after primary surgery (16 of 16 cases). EVT shows a similar healing rate to stent therapy (80–100%) but a shorter duration of treatment. The advantages of EVT are endoscopic access, internal drainage, rapid granulation, and direct therapy control. In compartmentalized gastric leaks, EVT was successful as a standalone therapy without external drainage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02365-9.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

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.

Bariatric surgery and the endoscopist

Bariatric surgery is an effective treatment for obesity and its metabolic related disorders. With the numbers of bariatric procedures being performed rising annually endoscopists are now more likely than ever to encounter this patient cohort on routine diagnostic lists. Endoscopy plays a vital role in both the pre and postoperative periods to diagnose and treat certain complications associated with bariatric surgery. Preoperative endoscopy may be useful in identifying pathologies that then influence the type of bariatric surgery being proposed. Postoperative endoscopy has an established role in identifying and managing complications such as anastomotic leaks and gastrointestinal bleeding. As endoscopic techniques develop, these complications may be managed without the need for surgical intervention or revision. Increased knowledge and awareness of the indications for endoscopy, together with the altered anatomy and common complications of bariatric surgery, is paramount in managing these patients effectively.

The role of endoprostheses in the treatment of leaks after laparoscopic sleeve gastrectomy. Analysis of a Spanish registry

It has been suggested that endoprostheses are an effective treatment for fistulae after sleeve gastrectomy, but the results published are very variable. To analyze the effectiveness of stents as treatment of leakage after sleeve gastrectomy, the Spanish Society of Obesity Surgery (SECO) and the Obesity Division of the Spanish Association of Surgeons (AEC) set up a National Registry to record treatments of leaks after sleeve gastrectomy. We have analyzed patients with leaks after sleeve gastrectomy and treated with endoprostheses: 19 medical centers reported the use of endoprostheses, where 51 endoprostheses were used in 42 patients (34 women/8 men, mean age: 43.8 years, BMI: 47.6). Global effectiveness was 45%, with a complication rate of 35%. Uni- and multivariate analyses detected no factors influencing the efficacy of treatment. A larger diameter bouggie used to calibrate the stomach was related to a higher incidence of complications. No factors were found related with better stent efficacy. The effectiveness of a second stent was very low when the previous one had not been effective.

Training in bariatric and metabolic endoscopy

The limited penetration of bariatric surgery and the scarce outcome of pharmacological therapies created a favorable space for primary bariatric endoscopic techniques. Furthermore, bariatric endoscopy is largely used to diagnose and treat surgical complications and weight regain after bariatric surgery. The increasingly essential role of endoscopy in the management of obese patients results in the need for trained professionals. Training methods are evolving, and the apprenticeship method is giving way to the simulation-based method. Existing simulation platforms include mechanical simulators, ex vivo and in vivo models, and virtual reality simulators. This review analyzes current training methods for bariatric endoscopy and available training programs with dedicated bariatric core curricula, giving a glimpse of future perspectives.

Trends in Utilization and Relative Complication Rates of Bariatric Procedures

BACKGROUND

Laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding have been popular alternatives to laparoscopic Roux-en-Y gastric bypass due to their technical ease and lower complication rates. Comprehensive longitudinal data are necessary to guide selection of the appropriate bariatric procedures for individual patients.

METHODS

We used the Truven Heath Analytics MarketScan® database between 2000 and 2015 to identify patients undergoing bariatric surgery. Kaplan-Meier and Cox proportional hazard regression analyses were performed to compare complication rates between laparoscopic gastric bypass and laparoscopic sleeve gastrectomy, as well as between laparoscopic gastric bypass and laparoscopic adjustable gastric banding.

RESULTS

256,830 individuals met search criteria. By 2015, laparoscopic sleeve gastrectomy was the most commonly performed bariatric procedure followed by laparoscopic gastric bypass and then laparoscopic adjustable gastric banding. Overall, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding had fewer complications relative to laparoscopic gastric bypass with the exceptions of heartburn, gastritis, and portal vein thrombosis following sleeve gastrectomy and heartburn and dysphagia following adjustable gastric banding.

CONCLUSION

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric procedure in the USA. It is reassuring that its overall postoperative complication rates are lower relative to laparoscopic gastric bypass.

Spontaneous Gastrojejunal Fistulization after Roux-en-Y Bypass Surgery: A Case Report and Review of Literature

Fistula development is an uncommon but well-recognized complication following Roux-en-Y gastric bypass (RYGB). The broad spectrum of clinical presentation represents a challenge at the time of diagnosis. We present the case of a patient who developed gastrojejunal fistulization after gastric bypass surgery.

The role of silent helicobacter pylori infection in intragastric ulcers induced by balloon insertion used for management of obesity

BACKGROUND

Obesity represents one of the common medical disorders that carries a high risk of morbidity and mortality. Insertion of intragastric balloon is one of the recently introduced lines of treatment of obesity. It allows patients to sense abdominal fullness and reduce their food intake. However, gastric ulceration may be a serious adverse effect that may be associated with intragastric balloon insertion.

AIM

To assess the role of silent helicobacter pylori infection in intragastric balloon-induced ulcers and to explore the possible methods for amelioration of this effect.

METHODS

Thirty patients were divided into 2 equal groups; one of them received triple therapy for helicobacter pylori eradication and the other group received placebo treatment. Then, they underwent intragastric balloon insertion. After removal of the balloon, gastroscopy was performed to evaluate the gastric mucosal lesions, if present.

RESULTS

There was significant decrease in the incidence of gastric erosions and ulcerations in the group that received triple therapy for helicobacter pylori eradication compared to the group that received placebo treatment.

CONCLUSION

Eradication of silent helicobacter pylori infection may represent a promising hope to decrease the incidence and improve symptoms of gastric erosions and ulceration that may be associated with intragastric balloon insertion.

Pancreatitis

Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.

Sleeve Gastrectomy: Surgical Tips

The vertical sleeve gastrectomy is a bariatric procedure that was originally described as the initial step in the biliopancreatic diversion. It demonstrated effectiveness in weight loss as a single procedure, and the laparoscopic vertical sleeve gastrectomy, as a stand-alone procedure, is now the most commonly performed bariatric surgery worldwide. Due to its relative technical ease and long-term data that have established its durability in treating obesity and its related comorbid conditions, the sleeve gastrectomy has grown in popularity among patients and surgeons. While there are variations in the technical aspects of performing a laparoscopic sleeve gastrectomy, key steps must be undertaken to produce safe and effective outcomes. This article reviews the indications for bariatric surgery, patient selection, surgical technique and tips, perioperative care and complications after sleeve gastrectomy.

Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae

Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.