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Kakuan M, Plamper A, Al-Taie O, Kroh A, Vondran F, Alizai PH, Ulmer TF, Schmitz SM, Rheinwalt KP. Analysis of intra- and postoperative interventional endoscopic measures in 3000 bariatric surgical procedures over 15 years: a single center study. Updates Surg 2025:10.1007/s13304-025-02239-5. [PMID: 40381183 DOI: 10.1007/s13304-025-02239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2024] [Accepted: 04/28/2025] [Indexed: 05/19/2025]
Abstract
In addition to preoperative diagnostic gastroscopy, some bariatric surgery patients require one or more differentiated endoscopic interventions as part of postoperative complication management. The aim of this study is to analyze endoscopic interventions regarding indication, type of procedure, material used, and outcome. We prospectively collected and retrospectively analyzed data over a period of 15 years from 2006 to 2021 of all consecutive patients who underwent an interventional upper gastrointestinal endoscopy after bariatric surgery at our center. The primary study objective was the type and frequency of the treatment. Secondary study objectives included clinical outcomes and postinterventional complications. Of 3000 bariatric procedures, 145 (4.8%), among them 11.1% (n = 54) of 485 Roux-en-Y gastric bypasses, 7.1% (n = 20) of 282 redo operations, 5.7% (n = 20) of 351 revisional operations, 3.3% (n = 13) of 398 sleeve gastrectomies, and 1.9% (n = 26) of 1394 one-anastomosis gastric bypasses, received an interventional endoscopy for postoperative complication management. 79.3% (n = 115) were female, mean age was 42.4 (± 10.7) years, mean BMI was 43.5 (± 9.8) kg/m2. Complication after interventional endoscopy happened in 1.6%, revisional surgery was necessary in 0.5% (n = 3). Causes for endoscopic intervention were stenosis (52.4%), leakage/fistula (35.9%), intraluminal bleeding (13.1%), dumping syndrome (9.0%), and gallstones (1.4%). The performed interventions were balloon dilation (48.3%), stent therapy (33.1%), metallic clipping (12.4%), injection therapy (0.09%), bougienage (0.07%), vacuum therapy (0.06%), and pigtail therapy (0.04%). Endoscopic intervention is an effective and safe way of treating adverse events after bariatric surgery. Stenosis and leakage were the most frequent complications, with endoscopic balloon dilatation and stent therapy as the most frequent and successful treatment options. RYGB was the procedure with the most endoscopic interventional involvement. To better learn about outcomes of specific endoscopic techniques further studies preferably with larger multicenter samples are required.
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Affiliation(s)
| | - Andreas Plamper
- Department of Bariatric, Metabolic and Plastic Surgery, Cellitinnen Hospital St. Franziskus Cologne, Cologne, Germany
| | - Oliver Al-Taie
- Department of Internal Medicine and Gastroenterology, Cellitinnen Hospital St. Franziskus Cologne, Cologne, Germany
| | - Andreas Kroh
- Department of General, Visceral, Pediatric and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Florian Vondran
- Department of General, Visceral, Pediatric and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Patrick H Alizai
- Department of General and Visceral Surgery, GKH St. Elisabeth/ St. Petrus/ St. Johannes, Bonn, Germany
| | - Tom F Ulmer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Sophia M Schmitz
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Karl P Rheinwalt
- Department of Bariatric, Metabolic and Plastic Surgery, Cellitinnen Hospital St. Franziskus Cologne, Cologne, Germany
- Department of General, Visceral, Pediatric and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
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Gipe J, Agathis AZ, Nguyen SQ. Managing Leaks and Fistulas After Laparoscopic Sleeve Gastrectomy: Challenges and Solutions. Clin Exp Gastroenterol 2025; 18:1-9. [PMID: 39802341 PMCID: PMC11724628 DOI: 10.2147/ceg.s461534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 12/31/2024] [Indexed: 01/16/2025] Open
Abstract
Postoperative leaks after sleeve gastrectomy are a troublesome complication that occur in 0.7-5.3% of cases depending on the referenced source. These complications cause significant morbidity for patients requiring prolonged hospitalizations, nutritional support, intravenous antibiotics, and at times additional operations and procedures that risk further downstream complications. The patient presentation varies from relatively benign with minimal or no symptomatology, to the acutely ill with life-threatening sepsis. The management of gastric leak is dependent on a multitude of factors, including the initial presentation as well the surgeon's experience and preference. Here, we will summarize the current literature and discuss the different options that exist for the management of gastric leaks after sleeve gastrectomy including laparoscopic lavage, endoscopic stenting, endoscopic pigtail catheters, endoscopic vacuum therapy, and salvage surgical operations such as fistula jejunostomy and total gastrectomy. The aim is to provide a source for surgeons to reference when they encounter this disease pathology and to shed light on a daunting challenge for the modern bariatric surgeon.
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Affiliation(s)
- Jordan Gipe
- Department of Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | - S Q Nguyen
- Department of Surgery, Mount Sinai Hospital, New York, NY, USA
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Lee S, Dang J, Chaivanijchaya K, Farah A, Kroh M. Endoscopic management of complications after sleeve gastrectomy: a narrative review. MINI-INVASIVE SURGERY 2024. [DOI: 10.20517/2574-1225.2024.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Sleeve gastrectomy (SG) has become the most widely performed bariatric procedure globally due to its technical simplicity and proven efficacy. However, complications following SG, including bleeding, leakage, fistulas, stenosis, gastroesophageal reflux disease (GERD), and hiatal hernia (HH), remain a significant concern. Endoscopic interventions have emerged as valuable minimally invasive alternatives to traditional surgical approaches for managing these complications. This review aims to provide a comprehensive overview of the endoscopic management strategies available for addressing the various complications encountered after SG, emphasizing their critical role in optimizing patient outcomes.
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Jung CFM, Binda C, Tuccillo L, Secco M, Gibiino G, Liverani E, Petraroli C, Coluccio C, Fabbri C. New Endoscopic Devices and Techniques for the Management of Post-Sleeve Gastrectomy Fistula and Gastric Band Migration. J Clin Med 2024; 13:4877. [PMID: 39201020 PMCID: PMC11355382 DOI: 10.3390/jcm13164877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/14/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Post-sleeve gastrectomy fistulas are a rare but possibly severe life-threatening complication. Besides early reoperation and drainage, endoscopy is the main treatment option. According to the clinical setting, endoscopic treatment options comprise stent or clip placement. New endoscopic therapies have recently gained attention, including endoscopic vacuum therapy, VacStent therapy, endoscopic internal drainage with pigtail stents, endoscopic suturing and stem cell injection. In this narrative review, we shed light on recent literature, developments, indications and contraindications of these treatments. Intragastric gastric band migration is a rare complication after gastric band positioning. Reoperation can sometimes be difficult, especially when a gastric band has already migrated far into the stomach. Endoscopic retrieval can be a valid, non-invasive therapeutic solution. We reviewed the current literature on this matter.
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Affiliation(s)
- Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forli-Cesena Hospitals, AUSL Romagna, 47121 Forlì, Italy
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Masood M, Low DE, Deal SB, Kozarek RA. Endoscopic Management of Post-Sleeve Gastrectomy Complications. J Clin Med 2024; 13:2011. [PMID: 38610776 PMCID: PMC11012813 DOI: 10.3390/jcm13072011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
| | - Donald E. Low
- Division of Thoracic Surgery, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Shanley B. Deal
- Division of General and Bariatric Surgery, Center for Weight Management, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Richard A. Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
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Nandipati KC, Bremer KC. Bariatric Surgery Emergencies in Acute Care Surgery. Surg Clin North Am 2023; 103:1113-1131. [PMID: 37838459 DOI: 10.1016/j.suc.2023.05.013] [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] [Indexed: 10/16/2023]
Abstract
Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.
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Affiliation(s)
- Kalyana C Nandipati
- Division of Clinical Research, Department of Surgery, Creighton University School of Medicine, Minimally Invasive Surgery, Creighton University Education Building, 7710 Mercy Road, Suite 501, Omaha, NE 68124-2368, USA.
| | - Kristin C Bremer
- Department of Surgery, Creighton University School of Medicine, Creighton University Education Building, 7710 Mercy Road, Suite 501, Omaha, NE 68124-2368, USA
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Kramer RE. The Role of Endoscopy in the Management of Adolescent Bariatric Patients: A Primer For Pediatric Gastroenterologists. Curr Gastroenterol Rep 2023; 25:299-307. [PMID: 37787883 DOI: 10.1007/s11894-023-00894-5] [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] [Accepted: 08/17/2023] [Indexed: 10/04/2023]
Abstract
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.
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Affiliation(s)
- Robert E Kramer
- Department of Pediatrics, University of Colorado School of Medicine, 13001 E 17Th Pl, Aurora, CO, 80045, USA.
- Digestive Health Institute, Children's Hospital of Colorado, 13123 E. 16th Ave B290, Aurora, CO, 80045, USA.
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Kollmann L, Reimer S, Lock JF, Flemming I, Widder A, May J, Krietenstein L, Gruber M, Meining A, Hankir M, Germer CT, Seyfried F. Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience. Surg Obes Relat Dis 2023; 19:1041-1048. [PMID: 36948972 DOI: 10.1016/j.soard.2023.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/04/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Gastric (anastomotic or staple-line) leaks after bariatric surgery are rare but potentially life-threatening complications. Endoscopic vacuum therapy (EVT) has evolved as the most promising treatment strategy for leaks associated with upper gastrointestinal surgery. OBJECTIVE The aim of this study was to evaluate the efficiency of our gastric leak management protocol in all bariatric patients over a 10-year period. Special emphasis was placed on EVT treatment and its outcome as a primary treatment or as a secondary treatment when other approaches failed. SETTING This study was performed at a tertiary clinic and certified center of reference for bariatric surgery. METHODS In this retrospective single-center cohort study, clinical outcomes of all consecutive patients after bariatric surgery from 2012 to 2021 are reported, with special emphasis placed on gastric leak treatment. The primary endpoint was successful leak closure. Secondary endpoints were overall complications (Clavien-Dindo classification) and length of stay. RESULTS A total of 1046 patients underwent primary or revisional bariatric surgery, of whom 10 (1.0%) developed a postoperative gastric leak. Additionally, 7 patients were transferred for leak management after external bariatric surgery. Of these, 9 patients underwent primary and 8 patients underwent secondary EVT after futile surgical or endoscopic leak management. The efficacy of EVT was 100%, and there were no deaths. Complications did not differ between primary EVT and secondary treatment of leaks. Length of treatment was 17 days for primary EVT versus 61 days for secondary EVT (P = .015). CONCLUSIONS EVT for gastric leaks after bariatric surgery led to rapid source control with a 100% success rate both as primary and secondary treatment. Early detection and primary EVT shortened treatment time and length of stay. This study underlines the potential of EVT as a first-line treatment strategy for gastric leaks after bariatric surgery.
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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Stanislaus Reimer
- Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ilona Flemming
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Anna Widder
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jana May
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Laura Krietenstein
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maximilian Gruber
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
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Kouladouros K. Applications of endoscopic vacuum therapy in the upper gastrointestinal tract. World J Gastrointest Endosc 2023; 15:420-433. [PMID: 37397978 PMCID: PMC10308278 DOI: 10.4253/wjge.v15.i6.420] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/15/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the "piggyback" technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Surgical Clinic, Mannheim University Hospital, University of Heidelberg, Mannheim 68167, Baden-Wuerttemberg, Germany
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10
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The Evolving Management of Leaks Following Sleeve Gastrectomy. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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Nedelcu M, Manos T, Noel P, Danan M, Zulian V, Vilallonga R, Nedelcu A, Carandina S. Is the Surgical Drainage Mandatory for Leak after Sleeve Gastrectomy? J Clin Med 2023; 12:jcm12041376. [PMID: 36835912 PMCID: PMC9963979 DOI: 10.3390/jcm12041376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
INTRODUCTION Despite the unanimous acknowledgement of the laparoscopic sleeve gastrectomy (LSG) worldwide, the leak remains its deficiency. For the last decade, the surgical treatment was practically considered mandatory for almost any collection following LSG. The aim of this study is to evaluate the need for surgical drainage for leak following LSG. METHODS All consecutive patients having gone through LSG from January 2017 to December 2020 were enrolled in our study. Once the demographic data and the leak history were registered, we analyzed the outcome of the surgical or endoscopic drainage, the characteristics of the endoscopic treatment, and the evolution to complete healing. RESULTS A total of 1249 patients underwent LSG and the leak occurred in 11 cases (0.9%). There were 10 women with a mean age of 47.8 years (27-63). The surgical drainage was performed for three patients and the rest of the eight patients underwent primary endoscopic treatment. The endoscopic treatment was represented with pigtails for seven cases and septotomy with balloon dilation for four cases. In two out of these four cases, the septotomy was anticipated by the use of a nasocavitary drain for 2 weeks. The average number of endoscopic procedures was 3.2 (range 2-6). The leaks achieved complete healing after an average duration of 4.8 months (range 1-9 months). No mortality was recorded for a leak. CONCLUSIONS The treatment of the gastric leak must be tailored to each patient. Although there is still no consensus for the endoscopic drainage of leaks after LSG, the surgical approach can be avoided in up to 72%. The benefits of pigtails and nasocavitary drains followed by endoscopic septotomy are undeniable, and they should be included in the armamentarium of any bariatric center.
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Affiliation(s)
- Marius Nedelcu
- ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Óbesite, 83000 Toulon, France
- ELSAN, Clinique Bouchard, 13006 Marseille, France
- Correspondence: ; Tel.: +33-695-950-965
| | - Thierry Manos
- ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Óbesite, 83000 Toulon, France
| | - Patrick Noel
- ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Óbesite, 83000 Toulon, France
- Emirates Specialty Hospital, Dubai Healthcare City, Dubai 505240, United Arab Emirates
- Mediclinic Airport Road Hospital, Abu Dhabi 48481, United Arab Emirates
| | - Marc Danan
- ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Óbesite, 83000 Toulon, France
| | - Viola Zulian
- ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Óbesite, 83000 Toulon, France
| | - Ramon Vilallonga
- ELSAN, Clinique Bouchard, 13006 Marseille, France
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Hospital Vall d’Hebron, 08035 Barcelona, Spain
- Surgery Department, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | | | - Sergio Carandina
- ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Óbesite, 83000 Toulon, France
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Binda C, Jung CFM, Fabbri S, Giuffrida P, Sbrancia M, Coluccio C, Gibiino G, Fabbri C. Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:136. [PMID: 36676760 PMCID: PMC9864982 DOI: 10.3390/medicina59010136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Paolo Giuffrida
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
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Raj PP, Gupta P, Kumar SS. Laparoscopic Sleeve Gastrectomy: Late (>30-Days) Complications – Diagnosis and Management. OBESITY, BARIATRIC AND METABOLIC SURGERY 2023:479-493. [DOI: 10.1007/978-3-030-60596-4_84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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14
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Hua F, Sun D, Zhao X, Song X, Yang W. Update on therapeutic strategy for esophageal anastomotic leak: A systematic literature review. Thorac Cancer 2022; 14:339-347. [PMID: 36524684 PMCID: PMC9891862 DOI: 10.1111/1759-7714.14734] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
Anastomotic leak is still a severe complication in esophageal surgery due to high mortality. This article reviews the updates on the treatment of anastomotic leak after esophagectomy in order to provide reference for clinical treatment and research. The relevant studies published in the Chinese Zhiwang, Wanfang, and MEDLINE databases to December 21, 2021 were retrieved, and esophageal carcinoma, esophagectomy, anastomotic leakage, and fistula selected as the keywords. A total of 78 studies were finally included. The treatments include traditional surgical drainage, new reverse drainage trans-fistula, stent plugging, endoscopic clamping, biological protein glue injection plugging, endoluminal vacuum therapy (EVT), and reoperation, etc. Early diagnosis, accurate classification and optimal treatment can promote the rapid healing of anastomotic leaks. EVT may be the most valuable approach, simultaneously with good commercial prospects. Reoperation should be considered in patients with complex fistula in which conservative treatment is insufficient or has failed.
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Affiliation(s)
- Feng Hua
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Dongfeng Sun
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Xiaoming Zhao
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Xuemin Song
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Wenfeng Yang
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
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15
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Mongardini FM, Cacciatore C, Catauro A, Maglione F, Picardi F, Lauro A, Gambardella C, Allaria A, Docimo L. Stemming the Leak: A Novel Treatment for Gastro-Bronchial Fistula. Dig Dis Sci 2022; 67:5425-5432. [PMID: 36251132 DOI: 10.1007/s10620-022-07711-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 01/05/2023]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is a commonly used procedure in bariatric patients that often has excellent results. Despite its advantages, LSG is burdened by specific intraoperative and postoperative early and late complications. One of the life-threatening complications is gastric fistula, usually treated with a multidisciplinary surgical-endoscopic approach. In case of failure of the latter, alternative nonoperative techniques such as the use of autologous stem cells truly represents an innovative possibility, with only few cases described in literature. Here, we report the case of a 25-year-old man with post-LSG broncho-gastric fistula treated with application of autologous stem cells after the failure of the conventional surgical/endoscopic approach.
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Affiliation(s)
- F M Mongardini
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - C Cacciatore
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Catauro
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - F Maglione
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - F Picardi
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Lauro
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy.,Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - C Gambardella
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Allaria
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - L Docimo
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
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16
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Intriago JMV, de Moura DTH, do Monte Junior ES, Proença IM, Ribeiro IB, Sánchez-Luna SA, Bernardo WM, de Moura EGH. Endoscopic Vacuum Therapy (EVT) for the Treatment of Post-Bariatric Surgery Leaks and Fistulas: a Systematic Review and Meta-analysis. Obes Surg 2022; 32:3435-3451. [PMID: 35918596 DOI: 10.1007/s11695-022-06228-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/21/2022] [Accepted: 07/24/2022] [Indexed: 11/26/2022]
Abstract
Bariatric surgery remains the most effective treatment for morbid obesity and its comorbidities. However, post-surgical leaks and fistulas can occur in about 1-5% of patients, with challenging treatment approaches. Endoscopic vacuum therapy (EVT) has emerged as a promising tool due to its satisfactory results and accessibility. In this first systematic review and meta-analysis on the subject, EVT revealed rates of 87.2% clinical success, 6% moderate adverse events, and 12.5% system dislodgements, requiring 6.47 EVT system exchanges every 4.39 days, with a dwell time of 25.67 days and a total length of hospitalization of 44.43 days. Although our results show that EVT is a safe and effective therapy for post-surgical leaks and fistulas, they should be interpreted with caution due to the paucity of available data.
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Affiliation(s)
- Josselyn Mariana Vera Intriago
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil
| | - Epifanio Silvino do Monte Junior
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil
| | - Igor Mendonça Proença
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil
| | - Igor Braga Ribeiro
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil.
| | - Sergio A Sánchez-Luna
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology & Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Wanderley Marques Bernardo
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil
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17
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Parmer M, Wang YHW, Hersh EH, Zhang L, Chin E, Nguyen SQ. Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy. JSLS 2022; 26:JSLS.2022.00029. [PMID: 36071996 PMCID: PMC9439287 DOI: 10.4293/jsls.2022.00029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure. Methods: A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019. Results: A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15–95 days). Conclusion: Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.
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Affiliation(s)
- Megan Parmer
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | | | - Eliza H Hersh
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Linda Zhang
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Edward Chin
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Scott Q Nguyen
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
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18
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Suter K, Bui HT, Chan STF. Management of Severe Sleeve Gastrectomy Leaks by a Roux-en-Y Gastrojejunostomy and Suction Isoperistaltic Jejuno-gastroesophagostomy Tube (SIJGET): a Novel Approach. Obes Surg 2022; 32:2816-2819. [PMID: 35687254 DOI: 10.1007/s11695-022-06147-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Katherine Suter
- Department of Surgery, Upper Gastrointestinal Surgery Unit, Western Health, 160 Gordon St, Melbourne, VIC, 3011, Australia.
| | - Hai T Bui
- Department of Surgery, Upper Gastrointestinal Surgery Unit, Western Health, 160 Gordon St, Melbourne, VIC, 3011, Australia.,Melbourne Medical School, Western Campus, The University of Melbourne, Melbourne, Australia
| | - Steven T F Chan
- Department of Surgery, Upper Gastrointestinal Surgery Unit, Western Health, 160 Gordon St, Melbourne, VIC, 3011, Australia.,Melbourne Medical School, Western Campus, The University of Melbourne, Melbourne, Australia
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19
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Kaczmarek DJ, Heling DJ, Strassburg CP, Katzer D, Düker G, Strohm J, Müller A, Heydweiller A, Weismüller TJ. Management of esophageal perforations in infants by endoscopic vacuum therapy: a single center case series. BMC Gastroenterol 2022; 22:282. [PMID: 35658914 PMCID: PMC9164384 DOI: 10.1186/s12876-022-02346-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 05/19/2022] [Indexed: 11/21/2022] Open
Abstract
Background Endoscopic vacuum therapy (EVT) has become a standard treatment method for esophageal perforations in adults. However, experience with EVT in infants is scarce. In this retrospective case series, we report on four very young infants who were successfully treated with EVT for esophageal perforations of different etiology. Methods Four infants were diagnosed with esophageal perforations on day 7, 32, 35 and 159 of life, respectively. The youngest one was prematurely born in the 31st week of pregnancy weighing 980 g only. Three infants had perforations due to foreign body insertion (nasogastric tube or pulling through of percutaneous endoscopic gastrostomy (PEG) tube through the esophagus). One child had an anastomotic dehiscence after Foker’s surgery for atresia. In three children EVT was applied as first-line therapy for perforation, in one child EVT was a rescue therapy due to persisting leakage after surgical closure involving thoracotomy. Depending on the esophageal diameter, either an open-pore drainage film or polyurethane sponge was attached to a single-lumen 8 Fr suction catheter, endoscopically (or fluoroscopically by wire-guidance) placed into the esophagus (intraluminal EVT) and supplied with continuous negative pressure (ranging between 75 and 150 mmHg). The EVT system was exchanged twice per week. Results Complete closure of the perforation/leakage could be achieved in all four infants (100%) after 22 days of continuous EVT (median value; range 7–39) and 4.5 EVT exchanges (median value; range 1–12). No serious adverse events occurred. Conclusions EVT is an effective and safe addition to our therapeutic armamentarium in the management of esophageal perforations irrespective of its etiology. Here we prove the feasibility of EVT even in very young infants. The use of an extra thin vacuum open-pore drainage film is helpful to cope with the small esophageal diameter. EVT settings and exchange rates similar to those known from adult treatment were used.
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20
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Laopeamthong I, Akethanin T, Kasetsermwiriya W, Techapongsatorn S, Tansawet A. Vacuum Therapy and Internal Drainage as the First-Line Endoscopic Treatment for Post-Bariatric Leaks: A Systematic Review and Meta-Analysis. Visc Med 2022; 38:63-71. [PMID: 35295893 PMCID: PMC8874239 DOI: 10.1159/000518946] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/06/2021] [Indexed: 02/03/2023] Open
Abstract
Introduction Several endoscopic methods can be employed to manage post-bariatric leaks. However, endoluminal vacuum therapy (EVT) and endoscopic internal drainage (EID) are relatively new methods, and studies regarding these methods are scarce. We performed a systematic review of the literature and a meta-analysis to evaluate the efficacy of EVT and EID. Methods Databases were searched for eligible studies. The clinical success of leak closure was the primary outcome of interest. A proportional meta-analysis was performed for pooling the primary outcome using a fixed-effects model. A meta-analysis or descriptive analysis of other outcomes was performed based on the data availability. Results Data from 3 EVT and 10 EID studies (n = 279) were used for evidence synthesis. The leak closure rates (95% confidence interval [CI]) of EVT and EID were 85.2% (75.1%-95.4%) and 91.6% (88.1%-95.2%), respectively. The corresponding mean treatment durations (95% CI) were 28 (2.4-53.6) and 78.4 (50.1-106.7) days, respectively. However, data about other outcomes were extremely limited; thus, a pooled analysis could not be performed. Conclusions Both EVT and EID were effective when used as the first-line treatment for post-bariatric leaks. However, larger studies must be conducted to compare the efficacy of the 2 interventions.
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Affiliation(s)
- Issaree Laopeamthong
- Vajira Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | - Wisit Kasetsermwiriya
- Vajira Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Suphakarn Techapongsatorn
- Vajira Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Amarit Tansawet
- Vajira Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand,*Amarit Tansawet,
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21
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Larsen M, Kozarek R. Therapeutic endoscopy for the treatment of post-bariatric surgery complications. World J Gastroenterol 2022; 28:199-215. [PMID: 35110945 PMCID: PMC8776527 DOI: 10.3748/wjg.v28.i2.199] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/08/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.
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Affiliation(s)
- Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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22
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Scavone G, Caltabiano G, Inì C, Castelli F, Falsaperla D, Basile A, Piazza L, Scavone A. Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications. Heliyon 2022; 8:e08857. [PMID: 35141438 PMCID: PMC8810407 DOI: 10.1016/j.heliyon.2022.e08857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/12/2022] [Accepted: 01/25/2022] [Indexed: 11/25/2022] Open
Abstract
Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.
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Affiliation(s)
- Giovanni Scavone
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, "Garibaldi Centro" Hospital, Piazza Santa Maria di Gesù, 5, 95124 Catania CT, Italy
| | - Giuseppe Caltabiano
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, "Garibaldi Centro" Hospital, Piazza Santa Maria di Gesù, 5, 95124 Catania CT, Italy
| | - Corrado Inì
- Department of Radiodiagnostic and Radiotherapy Unit, University Hospital Policlinico "G.Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Federica Castelli
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, "Garibaldi Centro" Hospital, Piazza Santa Maria di Gesù, 5, 95124 Catania CT, Italy
| | - Daniele Falsaperla
- Department of Radiodiagnostic and Radiotherapy Unit, University Hospital Policlinico "G.Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Basile
- Department of Radiodiagnostic and Radiotherapy Unit, University Hospital Policlinico "G.Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Luigi Piazza
- General and Emergency Surgery Department, "Garibaldi Centro" Hospital, Piazza Santa Maria di Gesù, 5, 95124 Catania CT, Italy
| | - Antonio Scavone
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, "Garibaldi Centro" Hospital, Piazza Santa Maria di Gesù, 5, 95124 Catania CT, Italy
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23
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Billmann F, Pfeiffer A, Sauer P, Billeter A, Rupp C, Koschny R, Nickel F, von Frankenberg M, Müller-Stich BP, Schaible A. Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used. Obes Surg 2022; 32:64-73. [PMID: 34731416 PMCID: PMC8752538 DOI: 10.1007/s11695-021-05467-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Gastric staple line leakage (GL) is a serious complication of laparoscopic sleeve gastrectomy (LSG), with a specific mortality ranging from 0.2 to 3.7%. The current treatment of choice is stent insertion. However, it is unclear whether the type of stent which is inserted affects treatment outcome. Therefore, we aimed not only to determine the effectiveness of stent treatment for GL but also to specifically clarify whether treatment outcome was dependent on the type of stent (small- (SS) or megastent (MS)) which was used. PATIENTS AND METHODS A single-centre retrospective study of 23 consecutive patients was conducted to compare the outcomes of SS (n = 12) and MS (n = 11) for the treatment of GL following LSG. The primary outcome measure was the success rate of stenting, defined as complete healing of the GL without changing the treatment strategy. Treatment change or death were both coded as failure. RESULTS The success rate of MS was 91% (10/11) compared to only 50% (6/12) for SS (p = 0.006). An average of 2.3 ± 0.5 and 6.8 ± 3.7 endoscopies were required to achieve healing in the MS and SS groups respectively (p < 0.001). The average time to resumption of oral nutrition was shorter in the MS group (1.4 ± 1.1 days vs. 23.1 ± 33.1 days, p = 0.003). CONCLUSIONS Stent therapy is only effective and safe for the treatment of GL after LSG if a MS is used. Treatment with a MS may not only increase treatment success rates but may also facilitate earlier resumption of oral nutrition and shorten the duration of hospitalization.
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Affiliation(s)
- Franck Billmann
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Aylin Pfeiffer
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Peter Sauer
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Adrian Billeter
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Christian Rupp
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Ronald Koschny
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | - Felix Nickel
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
| | | | - Beat Peter Müller-Stich
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany.
| | - Anja Schaible
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
- Interdisciplinary Endoscopic Center, University Hospital of Heidelberg, Im Neuenheimer Feld 420, D-69120, Heidelberg, Germany
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24
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Chandan S, Shen B, Kochhar GS. Therapeutic Endoscopy in Postoperative Pouch Complications. Clin Colon Rectal Surg 2022; 35:78-88. [PMID: 35069034 PMCID: PMC8763469 DOI: 10.1055/s-0041-1740032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ileal pouch-anal anastomosis (IPAA) or "J"-pouch as it is commonly referred to, is the treatment of choice in patients with medically refractory ulcerative colitis. IPAA can have infectious, inflammatory, and mechanical complications. Currently, there are no Food and Drug Administration-approved medical therapies for these complications. Surgery that may be eventually required can have significant morbidities due to the complexity of IPAA. Endoscopy is fast emerging as a leading modality of treatment for some of these pouch complications. Endoscopy in adjunct with medical treatment can help manage the majority of pouch-related disorders and improve the outcome.
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Affiliation(s)
- Saurabh Chandan
- Gastroenterology and Hepatology, CHI Health Creighton University Medical Center, Omaha, Nebraska
| | - Bo Shen
- Center for Ileal Pouch Disorders, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, New York
| | - Gursimran S. Kochhar
- Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania
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25
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Markus A, Henrik BJ, Benedikt R, Alexander H, Thomas B, Clemens S, Jan-Hendrik E. Endoscopic vacuum therapy in salvage and standalone treatment of gastric leaks after bariatric surgery. Langenbecks Arch Surg 2021; 407:1039-1046. [PMID: 34787705 PMCID: PMC9151560 DOI: 10.1007/s00423-021-02365-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/18/2021] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Ahrens Markus
- Department of Surgery, St. Vinzenz Hospital Dinslaken, Dinslaken, Germany.
- Department of General, Thorax, Transplant and Paediatric Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.
| | - Beckmann Jan Henrik
- Department of General, Thorax, Transplant and Paediatric Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Reichert Benedikt
- Department of General, Thorax, Transplant and Paediatric Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Hendricks Alexander
- Department of General, Thorax, Vascular and Transplant Surgery, University Hospital Rostock, Rostock, Germany
| | - Becker Thomas
- Department of General, Thorax, Transplant and Paediatric Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Schafmayer Clemens
- Department of General, Thorax, Vascular and Transplant Surgery, University Hospital Rostock, Rostock, Germany
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Catchlove W, Johari Y, Forrest E, Au A, Shaw K, Nottle P, Ellis S, Brown WA, Burton P. Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks. Surg Obes Relat Dis 2021; 18:205-216. [PMID: 34952796 DOI: 10.1016/j.soard.2021.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/14/2021] [Accepted: 11/07/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks. OBJECTIVE Multiple modalities have been advocated for the treatment of sleeve gastrectomy leak, and there remains no consensus on the best treatment paradigm. For more than 10 years, we have variably attempted luminal occlusive therapies and repeated endoscopic debridement as treatment options. By evaluating the outcomes from these approaches, we aimed to determine whether the first management strategy is superior to the second in terms of outcomes. METHODS Patients were analyzed by group (luminal occlusive therapy versus repeated endoscopic debridement). Leaks were then stratified by radiologic appearance on computed tomography, defined as phlegmon, collection, contrast medium leak, or fistula. The primary outcome was length of stay (LOS). Secondary outcomes were comprehensive complication index and the need for resection. RESULTS There were 54 patients, with 22 in the luminal occlusion group and 32 in the repeated debridement group. There was no difference in LOS (59.8 ± 41.6 versus 46.5 ± 51.2 days, P = .179) and no difference in the requirement for resection (4 versus 3 resections, p = .425). Subset analysis suggested that patients who underwent operative versus conservative management (P = .006) had a longer LOS. Excluding management strategy, radiologic appearance on admission significantly predicted LOS (P = .0053). Patients presenting with fistula (84 ± 25.4 days) and contrast medium leak (64.1 ± 40 days) had a significantly longer LOS than those diagnosed with phlegmon (13.5 ± 5.5 days). Radiologic appearance was predictive of complication severity (P < .0001) and salvage resection (P = .008). CONCLUSION There was no significant difference in outcomes between patients treated with intraluminal occlusion or repeated debridement. Initial radiologic appearance was predictive of LOS and complication severity. This highlights the need for routine use of a validated classification system in studies reporting outcomes and treatment of sleeve leaks.
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Affiliation(s)
- William Catchlove
- Oesophago-Gastric Bariatric Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, and Centre for Obesity Research and Education, Alfred Hospital, Melbourne, Victoria, Australia.
| | - Yazmin Johari
- Oesophago-Gastric Bariatric Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, and Centre for Obesity Research and Education, Alfred Hospital, Melbourne, Victoria, Australia
| | - Edward Forrest
- Oesophago-Gastric Bariatric Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Amos Au
- Oesophago-Gastric Bariatric Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Kalai Shaw
- Department of Surgery, Monash University, and Centre for Obesity Research and Education, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Nottle
- Oesophago-Gastric Bariatric Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Samantha Ellis
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Wendy A Brown
- Oesophago-Gastric Bariatric Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, and Centre for Obesity Research and Education, Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul Burton
- Oesophago-Gastric Bariatric Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, and Centre for Obesity Research and Education, Alfred Hospital, Melbourne, Victoria, Australia
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Kaczmarek DJ, Heling DJ, Gonzalez-Carmona MA, Strassburg CP, Branchi V, Matthaei H, Kalff J, Manekeller S, Glowka TR, Weismüller TJ. Management of post-operative pancreatic fistulas following Longmire-Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy. BMC Gastroenterol 2021; 21:425. [PMID: 34772366 PMCID: PMC8588716 DOI: 10.1186/s12876-021-02000-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/28/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Pylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT. METHODS We included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between - 100 and - 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed. RESULTS PGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8-38) and 3 EVT film/sponge exchanges (range 1-9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT. CONCLUSIONS EVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.
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Affiliation(s)
| | - Dominik J Heling
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | | | - Vittorio Branchi
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Jörg Kalff
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Steffen Manekeller
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Tim R Glowka
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Tobias J Weismüller
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.
- Department of Internal Medicine - Gastroenterology and Oncology, Vivantes Humboldt Hospital, Am Nordgraben 2, 13509, Berlin, Germany.
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Feng XC, Burch M. Management of Postoperative Complications Following Bariatric and Metabolic Procedures. Surg Clin North Am 2021; 101:731-753. [PMID: 34537140 DOI: 10.1016/j.suc.2021.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA
| | - Miguel Burch
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA.
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Manos T, Nedelcu M, Nedelcu A, Gagner M, Weiss AK, Bastid C, Carandina S, Noel P. Leak After Sleeve Gastrectomy: Updated Algorithm of Treatment. Obes Surg 2021; 31:4861-4867. [PMID: 34455540 DOI: 10.1007/s11695-021-05656-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is currently the most common procedure performed worldwide, and still the leak is considered the main limitation. After an initial enthusiasm for stents, the endoscopic treatment evolved including in the current management the septotomy with balloon dilatation and pigtails insertions. The aim of this study was to evaluate the updated algorithm of endoscopic treatment of leak following LSG including septotomy and balloon dilatation. METHODS All consecutive patients treated by endoscopy between January 2018 and March 2020 for leak following LSG were included in the current study. After recording the demographic and the leak history, we have analyzed the number of endoscopic sessions, the duration of treatment, and the healing rate of endoscopic treatment for 3 groups: A, small orifice (< 10 mm); B, large orifice (> 10 mm) and acute leak; and group C with large orifice and late leak. RESULTS A total of 53 patients received endoscopic treatment for leak following LSG. The leaks achieved complete healing after average duration of 3.2 months (range 1-7 months), 2.3 months for group A, 4.2 months for group B, and 3.7 months for group C. The average number of endoscopic procedures was 2.8 (range 2-6) and was required for general population: for group A, 2.3 sessions; in group B, 3.4 sessions; and in group C, 2.7 sessions. Two out of 53 patients (3.8%) required additional treatment outside of the current algorithm, one in group A and another in group B. One patient was transferred for pulmonary abscess, and for another patient, the leak was considered chronic after a total of 14 months, and a laparoscopic fistula-jejunostomy was performed with favorable outcomes. CONCLUSIONS Although there is still no consensus for endoscopic management of leaks after LSG, the benefits of pigtails and the septotomy are undeniable, and it should be included in the armamentarium of any bariatric endoscopic service.
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Affiliation(s)
- Thierry Manos
- ELSAN, Clinique Bouchard, 77 Rue de Dr. Escat, 13006, Marseille, France
| | - Marius Nedelcu
- ELSAN, Clinique Bouchard, 77 Rue de Dr. Escat, 13006, Marseille, France. .,ELSAN, Clinique Saint Michel, Centre Chirurgical de L'Obésité, Place du 4 Septembre, 83100, Toulon, France.
| | - Anamaria Nedelcu
- ELSAN, Clinique Saint Michel, Centre Chirurgical de L'Obésité, Place du 4 Septembre, 83100, Toulon, France
| | | | - Abdul Kader Weiss
- Emirates Specialty Hospital, Dubai Healthcare City, Dubai, United Arab Emirates
| | - Christophe Bastid
- ELSAN, Clinique Bouchard, 77 Rue de Dr. Escat, 13006, Marseille, France
| | - Sergio Carandina
- ELSAN, Clinique Saint Michel, Centre Chirurgical de L'Obésité, Place du 4 Septembre, 83100, Toulon, France
| | - Patrick Noel
- ELSAN, Clinique Bouchard, 77 Rue de Dr. Escat, 13006, Marseille, France.,Emirates Specialty Hospital, Dubai Healthcare City, Dubai, United Arab Emirates.,Mediclinic Airport Road, Abu Dhabi, United Arab Emirates
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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: 16] [Impact Index Per Article: 4.0] [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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Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations. Pol J Radiol 2021; 86:e325-e334. [PMID: 34136051 PMCID: PMC8186309 DOI: 10.5114/pjr.2021.106795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/06/2020] [Indexed: 11/17/2022] Open
Abstract
In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.
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Chung Y, Park DG, Kim YJ. Endoscopic Management of Staple Line Leak after Bariatric Surgery: Surgeon's Perspective. Clin Endosc 2021; 54:805-809. [PMID: 33975425 PMCID: PMC8652167 DOI: 10.5946/ce.2020.298] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/20/2021] [Indexed: 11/14/2022] Open
Abstract
Laparoscopic sleeve gastrectomy (LSG) has become a standalone primary procedure as a bariatric metabolic surgery since the early 2000s. The overall complication rate of LSG is reported to range from 2% to 15%. Staple line leakage (SLL) remains a major adverse event and occurs in approximately 1–6% of patients. Choosing the optimal treatment modality is a complex process. Clinicians must understand that nutritional support and drainage of fluid collection are essential for initial management. Conservative endoscopic management and sufficient drainage can resolve approximately 70% of SLLs. Endoscopic management of bariatric complications has been rapidly evolving in recent years and can be considered in all patients who are hemodynamically stable. We will review the available endoscopic management techniques, including stent placement (self-expanding stents and bariatric-specific stents), clipping, tissue sealant application, and internal drainage (double-pigtail stents [DPS] placement, endoscopic vacuum therapy, and septotomy). Stent placement remains the mainstream treatment for SLLs. However, healing with stents requires multiple sessions/stents and a long course of recovery. Endoscopic internal drainage is gaining popularity and has the potential to be a superior method. The importance of early intervention and combined endoscopic methods should be recognized.
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Affiliation(s)
- Yoona Chung
- Bariatric and Metabolic Surgery Center, H+ Yangji Hospital, Seoul, Korea
| | - Dae Geun Park
- Bariatric and Metabolic Surgery Center, H+ Yangji Hospital, Seoul, Korea
| | - Yong Jin Kim
- Bariatric and Metabolic Surgery Center, H+ Yangji Hospital, Seoul, Korea
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Steinbichler TB, Wolfram D, Runge A, Hartl R, Dejaco D, Rauchenwald T, Pototschnig C, Riechelmann H, Schartinger VH. Modified vacuum-assisted closure (EndoVAC) therapy for treatment of pharyngocutaneous fistula: Case series and a review of the literature. Head Neck 2021; 43:2377-2384. [PMID: 33830587 PMCID: PMC9542148 DOI: 10.1002/hed.26684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/23/2021] [Accepted: 03/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pharyngocutaneous fistula is a potential life-threatening complication following head and neck surgery. There is only limited evidence about the efficacy of vacuum-assisted closure (VAC) therapy and endoscopic vacuum-assisted closure (EndoVAC) therapy for the treatment of pharyngocutaneous fistulas. METHODS In this article, we report on a consecutive case series of six male patients with pharyngocutaneous fistula treated with a modified outside-in EndoVAC technique. We also present a review of the current related literature. RESULTS EndoVAC therapy alone was successful in five of the six patients (83.3%) with a median duration of EndoVAC therapy of 18.5 days (range: 7 to 32 days) and a median number of EndoVAC sponge changes of 4 (range: 1 to 9 changes). One patient needed additional reconstructive surgery after prior radiochemotherapy and jejunal transfer. No treatment-related complications were observed. CONCLUSION EndoVAC therapy is an easy-to-perform, safe procedure for the treatment of pharyngocutaneous fistulae.
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Affiliation(s)
| | - Dolores Wolfram
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Annette Runge
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Roland Hartl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Dejaco
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Tina Rauchenwald
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claus Pototschnig
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert Riechelmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Volker Hans Schartinger
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Satoskar S, Kashyap S, Benavides F, Jones R, Angelico R, Singhal V. Success of endoscopic vacuum therapy for persistent anastomotic leak after esophagectomy - A case report. Int J Surg Case Rep 2021; 80:105342. [PMID: 33547016 PMCID: PMC7982496 DOI: 10.1016/j.ijscr.2020.11.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Endoscopic vacuum (endovac) therapy has shown excellent outcomes when used for esophageal anastomotic leaks. The results of endovac therapy are superior to those of other endoscopic therapies for esophageal leaks. CASE PRESENTATION We present a case of a 70-year-old male with esophageal adenocarcinoma who underwent Ivor Lewis esophagogastrectomy that was complicated by an esophageal leak. After failure of multiple endoscopic therapies (i.e. stents and clips), he responded well to endovac therapy. DISCUSSION Endovac therapy is extremely useful for the treatment of esophageal leaks. The widespread use of endovac therapy is feasible, even in smaller community hospitals. CONCLUSION Endovac therapy is a valuable tool that can be used widely for the management of esophageal leaks. Commercially available devices need to be developed in order to facilitate endovac placement and exchange so that the procedure is less dependent on the skill of the operator.
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Affiliation(s)
- Savni Satoskar
- Easton Hospital, 250 S 21st Street, Easton, PA, 18042, United States; St Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, United States.
| | - Sarang Kashyap
- Easton Hospital, 250 S 21st Street, Easton, PA, 18042, United States; Beckley ARH Hospital, 306 Stanaford Rd, Beckley, WV, 25801, United States
| | - Francisco Benavides
- Easton Hospital, 250 S 21st Street, Easton, PA, 18042, United States; St Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, United States
| | - Robert Jones
- Mount Sinai Hospital Chicago, 1500 South Fairfield Avenue, Chicago, IL, 60608, United States
| | - Richard Angelico
- Easton Hospital, 250 S 21st Street, Easton, PA, 18042, United States
| | - Vinay Singhal
- Easton Hospital, 250 S 21st Street, Easton, PA, 18042, United States; St Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, United States
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Mizrahi I, Grinbaum R, Elazary R, Mordechay-Heyn T, Kahahna N, Epshtein J, Jacob H, Beglaibter N. Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy: Low Efficacy of the Over-the-Scope Clip. Obes Surg 2021; 31:813-819. [PMID: 33047293 DOI: 10.1007/s11695-020-05036-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC. RESULTS Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35 years (range 18-62), and mean body mass index was 44 kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18 days (range 2-118), and 6 days (range 1-120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43 days of clip deployment (range 5-87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2). CONCLUSIONS OTSC carries a low success rate for controlling staple line leaks following LSG.
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Affiliation(s)
- Ido Mizrahi
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
- General Surgery, Hadassah-Hebrew University Medical Center Mount Scopus, P.O.B. 24035, 91240, Jerusalem, Israel.
| | - Ronit Grinbaum
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tzlil Mordechay-Heyn
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Noam Kahahna
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Julia Epshtein
- Department of Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Harold Jacob
- Department of Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Nahum Beglaibter
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Gastro-colo-diaphragmatic fistula after sleeve gastrectomy. Int J Surg Case Rep 2021; 79:394-397. [PMID: 33517211 PMCID: PMC7848736 DOI: 10.1016/j.ijscr.2021.01.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 11/20/2022] Open
Abstract
Gastro-colo-diaphragmatic fistula (GCD) following sleeve gastrectomy is an extremely rare complication. The clinical presentation of chronic fistula following sleeve gastrectomy varies widely and depends on the type of fistula. Management requires a multidisciplinary approach and patient cooperation Introduction Postsleeve gastrectomy fistula is a serious complication, and its management remains quite challenging. The clinical presentation of chronic fistula after sleeve gastrectomy (SG) varies widely and depends on the type of fistula. Management requires a multidisciplinary approach and patient cooperation. Case presentation We present a case of a 41-year-old woman with a body mass index (BMI) of 46 kg/m2 who initially underwent laparoscopic sleeve gastrectomy in our hospital. Later, she developed a gastro-colo-diaphragmatic fistula (GCD), which was successfully treated using an endolaparoscopic approach. Follow-up imaging and endoscopy showed complete healing of the fistula, as well as a marked clinical improvement of the patient. Discussion Gastro-colo-diaphragmatic fistula following sleeve gastrectomy is an extremely rare complication. This is the first case of a GCD fistula after sleeve gastrectomy that has been reported in the literature. Conclusion One staged endolaparoscopic management was successful approach in our case and can be considered for complex gastric fistula following sleeve gastrectomy.
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Kroh M. Comment on: Aortic injuries following stents in bariatric surgery: our experience. Surg Obes Relat Dis 2021; 17:e19-e20. [PMID: 33648888 DOI: 10.1016/j.soard.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Matthew Kroh
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE; Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
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Li S, Jiao S, Zhang S, Zhou J. Revisional Surgeries of Laparoscopic Sleeve Gastrectomy. Diabetes Metab Syndr Obes 2021; 14:575-588. [PMID: 33603423 PMCID: PMC7882429 DOI: 10.2147/dmso.s295162] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.
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Affiliation(s)
- Siyuan Li
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Siqi Jiao
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Siwei Zhang
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Jiangjiao Zhou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Correspondence: Jiangjiao Zhou Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, 410011, People’s Republic of China Email
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Bhurwal A, Mutneja H, Tawadross A, Pioppo L, Brahmbhatt B. Gastrointestinal fistula endoscopic closure techniques. Ann Gastroenterol 2020; 33:554-562. [PMID: 33162732 PMCID: PMC7599355 DOI: 10.20524/aog.2020.0543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022] Open
Abstract
With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.
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Affiliation(s)
- Abhishek Bhurwal
- Department of Gastroenterology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ (Abhishek Bhurwal, Augustine Tawadross, Lauren Pioppo)
| | - Hemant Mutneja
- Department of Gastroenterology, John H Stroger Cook County Hospital, Chicago, Illinois (Hemant Mutneja)
| | - Augustine Tawadross
- Department of Gastroenterology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ (Abhishek Bhurwal, Augustine Tawadross, Lauren Pioppo)
| | - Lauren Pioppo
- Department of Gastroenterology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ (Abhishek Bhurwal, Augustine Tawadross, Lauren Pioppo)
| | - Bhaumik Brahmbhatt
- Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida (Bhaumik Brahmbhatt), USA
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King DC, Shaw TB, Moremen JR. Successful Closure of a Chronic Gastric Fistula Cavity Using Endoluminal Vacuum Therapy. Am Surg 2020; 88:1322-1324. [PMID: 33118373 DOI: 10.1177/0003134820942206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dakota C King
- 21693 Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Taylor B Shaw
- 21693 Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jacob R Moremen
- 21693 Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
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Laparoscopic revision to total gastrectomy or fistulo-jejunostomy as a definitive surgical procedure for chronic gastric fistula after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:1893-1900. [PMID: 32928679 DOI: 10.1016/j.soard.2020.07.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Staple-line leaks (SLL) after sleeve gastrectomy (SG) are a rare but serious complication requiring radiologic and endoscopic interventions with varying degrees of success. When failed, a chronic gastrocutaneous fistula forms with decreasing chances of closure with time. Definitive surgical management of chronic SLL after SG include laparoscopic revision to total/subtotal gastrectomy (LTG/LSTG) or a fistulo-jejunostomy (LRYFJ), both with Roux-en-Y reconstruction. OBJECTIVES Comparison of SG revisions to LTG/LSTG versus LRYFJ as a definitive treatment for chronic SLL. SETTING High-volume bariatric unit. METHODS Retrospective review of a prospectively maintained database identified 17 patients with chronic gastric fistula after SG that were revised to either LTG/LSTG or LRYFJ between September 2011 and May 2020. Demographic characteristics, clinical data, quality of life, and laboratory values for both options were compared. RESULTS Of the 17 conversions, 8 were revised to LTG/LSTG and 9 to LRYFJ. Mean age and body mass index at revision were 36.85 years (range, 21-66 yr) and 29 kg/m2 (range, 21-36 kg/m2), respectively. Average preoperative endoscopic attempts was 5 (range, 1-16). The overall average operation time of revision was 183 minutes (range, 130-275 min) with no significant difference between either conversion options. Mean follow-up time was 46.5 months (range, 1-81 mo) and was available for 10 patients (58.8%). Food intolerance was significantly better after revision to LRYFJ (n = 6/6, 100% versus n = 1/5, 20%, P < .05). There were no significant differences between revisional procedures and laboratory abnormalities. CONCLUSION Laparoscopic revision to LRYFJ is a safe and feasible treatment for chronic SLL.
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Schulman AR, Watson RR, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Jirapinyo P, Krishnan K, Kumta NA, Melson J, Pannala R, Parsi MA, Trikudanathan G, Trindade AJ, Maple JT, Lichtenstein DR. Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos). Gastrointest Endosc 2020; 92:492-507. [PMID: 32800313 DOI: 10.1016/j.gie.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type. METHODS The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized. RESULTS Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving. CONCLUSIONS Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.
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Affiliation(s)
- Allison R Schulman
- Department of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Factors that promote successful endoscopic management of laparoscopic sleeve gastrectomy leaks. Surg Endosc 2020; 35:4638-4643. [PMID: 32780233 DOI: 10.1007/s00464-020-07890-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/05/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Staple line leaks following laparoscopic sleeve gastrectomy (LSG) are associated with significant morbidity and mortality. Endoluminal techniques, including stent placement and endoluminal vacuum therapy (EVAC), have become viable options to treat these patients without the need for additional surgery. The purpose of this study was to define the conditions where certain endoscopic therapies are most likely to succeed compared to surgery. METHODS An IRB approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to March 2019. All patients who were treated for gastrointestinal leaks following LSG were included. Endpoints include success of leak closure and hospital-related morbidity for the patients treated solely by endoscopic only methods (EP) compared to the additional surgery group (SP). RESULTS There were 39 patients (33 females; 6 males) with a median age of 45.9 years. The EP group included 23 patients (59%), whereas SP included 16 patients (31%). On average, the SP had longer days from sentinel surgery to our hospital admission (70 vs 41), a higher percentage of previous bariatric surgery prior to sentinel LSG (50% vs 17%), and a higher readmission rates following discharge (50% vs 39%). Total length of stay was also higher in the SP compared to the EP (45.4 vs 11). Using this data, a treatment algorithm was developed to optimally treat future patients who suffer from gastrointestinal leaks following LSG. CONCLUSIONS Endoscopic therapies, such as EVAC, stent placement, internal drainage, and over-the-scope clips, have a higher chance of success if performed earlier to their sentinel surgery and if patients have had no prior bariatric surgeries. Patients who require additional surgery tend to have longer hospital stays and readmission rates. Using the treatment algorithm provided can help determine when endoscopic therapies are likely to succeed.
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Caiazzo R, Marciniak C, Wallach N, Devienne M, Baud G, Cazauran JB, Kipnis E, Branche J, Robert M, Pattou F. Malignant Leakage After Sleeve Gastrectomy: Endoscopic and Surgical Approach. Obes Surg 2020; 30:4459-4466. [PMID: 32623688 DOI: 10.1007/s11695-020-04818-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Endoscopic internal drainage by double pigtail stents in the management of laparoscopic sleeve gastrectomy leaks. Surg Obes Relat Dis 2020; 16:831-838. [DOI: 10.1016/j.soard.2020.03.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/17/2022]
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Tatarian T, Rona KA, Shin DH, Chen DG, Ducoin CG, Moore RL, Brunaldi VO, Galvão-Neto M, Ardila-Gatas J, Docimo S, Hourneax de Moura DT, Jirapinyo P, Thompson CC, Billy HT, Roslin MS, Borden B, Zarabi S, Sweigert PJ, Chand B, Pryor AD. Evolving procedural options for the treatment of obesity. Curr Probl Surg 2020; 57:100742. [DOI: 10.1016/j.cpsurg.2020.100742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Low Postoperative Levels of C-Reactive Protein Are an Early Predictor for an Uncomplicated Course After Bariatric Surgery: A Retrospective, Validated Cohort Study. Surg Laparosc Endosc Percutan Tech 2020; 30:238-244. [PMID: 32032332 DOI: 10.1097/sle.0000000000000767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bariatric surgery is popularly used to treat or prevent morbidity in severely obese patients. Severe complications are rare, but their early detection has a significant impact on clinical outcomes. We aimed to determine whether blood tests in the first few postoperative days are reliable predictors for complications. METHODS We retrospectively analyzed 1073 patients who underwent laparoscopic bariatric surgery between 2009 and 2018 at our center. Clinical outcome was correlated with postoperative serum C-reactive protein (CRP), white blood cell count, and vital signs, analyzed using a receiver operating characteristic (ROC) curve. A total of 570 procedures between 2009 and 2015 were used to calculate the best cutoff values (calculation group), which were validated with 330 different patients operated upon between 2016 and 2018 (validation group). RESULTS Twenty-four patients (4.2%) developed anastomotic or staple-line leakages in the calculation group. The ROC curve showed a good reliability for CRP levels on day 2 (area under the ROC curve=0.86); the highest Youden index existed for a cutoff of 119 mg/L. White blood cell count and heart rate were poor predictors. Even though several characteristics differed in the validation cohort, test quality of the cutoff was high (sensitivity, 71.4%; specificity, 94.9%; positive predictive value, 23.8%; negative predictive value, 99.3%). The prediction was excellent especially for leakages appearing on days 2 to 9 (sensitivity 100.0%, negative predictive value 100%). Leakages from day 10 were rare and prediction poor (sensitivity 0%). CONCLUSIONS A CRP level on day 2 <120 mg/L is a good predictor of a postoperative course without leakage, even though the predictive value goes down for late-appearing events. An earlier CRP measurement added no predictive benefit. The cutoff value was validated in an internal cohort and could be applied to different populations.
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Archid R, Wichmann D, Klingert W, Nadiradze G, Hönes F, Archid N, Othman AE, Ahmad SJS, Königsrainer A, Lange J. Endoscopic Vacuum Therapy for Staple Line Leaks after Sleeve Gastrectomy. Obes Surg 2019; 30:1310-1315. [DOI: 10.1007/s11695-019-04269-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Granata A, Amata M, Ligresti D, Martino A, Tarantino I, Barresi L, Traina M. Endoscopic management of post-surgical GI wall defects with the overstitch endosuturing system: a single-center experience. Surg Endosc 2019; 34:3805-3817. [PMID: 31583467 DOI: 10.1007/s00464-019-07145-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/24/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Post-GI surgical wall defects are frequent and life-threatening complications, with limited literature regarding current treatment. This case series aims to assess the safety, feasibility, and outcomes of endoluminal therapy with the overstitch endoscopic suturing system (Apollo Endosurgery Inc, Austin). MATERIALS AND METHODS All patients who underwent endoscopic suturing for post-surgical wall defect management at IRCCS-ISMETT Palermo from October 2017 until January 2019 were retrospectively enrolled. Stratification therapy was applied according to the clinical scenario, time from surgery to endoscopic intervention, and structural condition of the wall defect layers (tissue status and suture feasibility). The therapeutic endoscopic strategy was divided into three groups (A: pure endoscopic direct suture; B: combined therapy with endoscopic direct suture + FC-SEMS placement + anchoring; C: FC-SEMS placement + anchoring). Success was considered the resolution of symptoms and the presence of a regular intestinal transit after a period of 4-6 weeks. RESULTS Twenty (20) patients (male/female 7/13; mean age 54 ± 13.43 years) were included in the study (group A: 9 patients, group B: 7 patients, group C: 4 patients). The types of operative procedures were bariatric (9/20), post-tracheostomy (3/20), post-operative GI surgery (8/20). The post-surgical defects were predominantly intermediate and chronic (24-72 h: 1/20; 3-30 days: 13/20; > 30 days: 6/20). The overall clinical success was 80% (17/20 patients), with a success of 94% (16/17 patients) when excluding the three cases of tracheo-esophageal fistula. No evidence of migration was detected. The only complication was short stenosis of the distal esophagus, present in 4 patients (19%) and successfully treated with a novel lumen-apposing metal stent. CONCLUSIONS In our experience, considering the absence of clear guidelines, the endoluminal approach with the overstich endoscopic suturing system is a valid alternative to conventional therapy, offering mini-invasiveness, and presenting promising opportunities in terms of technical feasibility and clinical efficacy.
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Affiliation(s)
- Antonino Granata
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Via Tricomi 5, 90127, Palermo, Italy
| | - Michele Amata
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Via Tricomi 5, 90127, Palermo, Italy.
| | - Dario Ligresti
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Via Tricomi 5, 90127, Palermo, Italy
| | - Alberto Martino
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Via Tricomi 5, 90127, Palermo, Italy
| | - Ilaria Tarantino
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Via Tricomi 5, 90127, Palermo, Italy
| | - Luca Barresi
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Via Tricomi 5, 90127, Palermo, Italy
| | - Mario Traina
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Via Tricomi 5, 90127, Palermo, Italy
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Gagner M. Comment on: Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review. Surg Obes Relat Dis 2019; 15:1419. [DOI: 10.1016/j.soard.2019.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 05/14/2019] [Accepted: 05/18/2019] [Indexed: 12/20/2022]
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