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Firkins SA, Simons-Linares R. Management of leakage and fistulas after bariatric surgery. Best Pract Res Clin Gastroenterol 2024; 70:101926. [PMID: 39053976 DOI: 10.1016/j.bpg.2024.101926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Stephen A Firkins
- Bariatric and Metabolic Endoscopy, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Roberto Simons-Linares
- Bariatric and Metabolic Endoscopy, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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2
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Gala K, Brunaldi V, Abu Dayyeh BK. Endoscopic Management of Surgical Complications of Bariatric Surgery. Gastroenterol Clin North Am 2023; 52:719-731. [PMID: 37919023 DOI: 10.1016/j.gtc.2023.08.004] [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: 11/04/2023]
Abstract
Bariatric surgery, although highly effective, may lead to several surgical complications like ulceration, strictures, leaks, and fistulas. Newer endoscopic tools have emerged as safe and effective therapeutic options for these conditions. This article reviews post-bariatric surgery complications and the role of endoscopy in their management.
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Affiliation(s)
- Khushboo Gala
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Vitor Brunaldi
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA.
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3
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Dolan RD, Jirapinyo P, Maahs ED, Thompson CC. Endoscopic closure versus surgical revision in the management of gastro-gastric fistula following Roux-en-Y gastric bypass. Endosc Int Open 2023; 11:E629-E634. [PMID: 37397860 PMCID: PMC10310440 DOI: 10.1055/a-2037-4764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 05/09/2022] [Indexed: 07/04/2023] Open
Abstract
Background and study aims Gastro-gastric fistulae (GGF) occur in 1.3 % to 6 % of Rouxy-en-Y gastric bypass (RYGB) patients and can be associated with abdominal pain, reflux, weight regain and onset of diabetes. Endoscopic and surgical treatments are available without prior comparisons. The study aim was to compare endoscopic and surgical treatment methods in RYGB patients with GGF. Patients and methods A retrospective matched cohort study of RYGB patients who underwent endoscopic closure (ENDO) or surgical revision (SURG) for GGF. One-to-one matching was performed based on age, sex, body mass index and weight regain. Patient demographics, GGF size, procedural details, symptoms and treatment-related adverse events (AEs) were collected. A comparison of symptom improvement and treatment-related AEs was performed. Fisher's Exact, t -test and Wilcoxon Rank Sum tests were performed. Results Ninety RYGB patients with GGF (45 ENDO, 45 matched SURG) were included. GGF symptoms included weight regain (80 %), gastroesophageal reflux disease (71 %) and abdominal pain (67 %). At 6 months, the ENDO and SURG groups experienced 0.59 % and 5.5 % total weight loss (TWL) ( P = 0.0002). At 12 months, the ENDO and SURG groups experienced 1.9 % and 6.2 % TWL ( P = 0.007). Abdominal pain improved in 12 (52.2 %) ENDO and 5 (15.2 %) SURG patients at 12 months ( P = 0.007). Diabetes and reflux resolution rates were similar between groups. Treatment-related AEs occurred in four (8.9 %) ENDO and 16 (35.6 %) SURG patients ( P = 0.005), of which none and eight (17.8%), respectively, were serious ( P = 0.006). Conclusions Endoscopic GGF treatment produces greater improvement in abdominal pain and fewer overall and serious treatment-related AEs. However, surgical revision appears to yield greater weight loss.
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Affiliation(s)
- Russell D. Dolan
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Ethan D. Maahs
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital, Boston, Massachusetts, United States
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de Oliveira VL, Bestetti AM, Trasolini RP, de Moura EGH, de Moura DTH. Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations. World J Gastroenterol 2023; 29:1173-1193. [PMID: 36926665 PMCID: PMC10011956 DOI: 10.3748/wjg.v29.i7.1173] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/28/2022] [Accepted: 01/30/2023] [Indexed: 02/21/2023] Open
Abstract
Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.
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Affiliation(s)
- Victor Lira de Oliveira
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Alexandre Moraes Bestetti
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Roberto Paolo Trasolini
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 021115, United States
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, 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, São Paulo 05403010, Brazil
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El Djouzi S. Endoscopic Evaluation of the Bariatric Surgery Patient. THE SAGES MANUAL OF PHYSIOLOGIC EVALUATION OF FOREGUT DISEASES 2023:215-233. [DOI: 10.1007/978-3-031-39199-6_16] [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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Griffith JP, Abrol S, Wertis E, Hardie AD. Use of dual energy CT to identify gastrointestinal anastomotic leak by assessment of percutaneous drain contents. Radiol Case Rep 2022; 18:108-111. [PMID: 36324834 PMCID: PMC9619327 DOI: 10.1016/j.radcr.2022.09.097] [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: 09/20/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
Anastomotic leakage is a feared complication of many different types of gastrointestinal surgery. It is important to identify patients with leaks early because sepsis may develop quickly. Suspected leaks are typically confirmed by either fluoroscopy or computed tomography with oral contrast. This article presents a novel method to confirm the presence of a gastrointestinal anastomotic leak when standard imaging and clinical presentation are ambiguous.
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Wei MT, Ahn JY, Friedland S. Over-the-Scope Clip in the Treatment of Gastrointestinal Leaks and Perforations. Clin Endosc 2021; 54:798-804. [PMID: 34872236 PMCID: PMC8652163 DOI: 10.5946/ce.2021.250] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 12/18/2022] Open
Abstract
While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management.
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Affiliation(s)
- Mike T Wei
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ji Yong Ahn
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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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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Kim HS, Kim Y, Han JH. Endoscopic salvage treatment of histoacryl after stent application on the anastomotic leak after gastrectomy: A case report. World J Clin Cases 2021; 9:262-266. [PMID: 33511194 PMCID: PMC7809665 DOI: 10.12998/wjcc.v9.i1.262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/09/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic approach could effectively manage postoperative anastomotic leakage. Various endoscopic methods have been developed for the treatment of anastomotic leakage.
CASE SUMMARY A 53-year-old woman developed anastomotic leak after laparoscopic proximal gastrectomy. Endoscopic clip closure failed due to strong wall tension; therefore, a fully covered self-expandable esophageal metal stent (fc-SEMS) was placed to cover the leak after it was filled with a mixture of fibrin glue and histoacryl. However, fluoroscopy with gastrograffin showed dye leaking out of the fc-SEMS. Using the previous fluoroscopic image for guidance, a catheter was inserted at the leakage site. The radiocontrast dye was injected and was seen spreading along the sinus tract. Thereafter, histoacryl was injected. Seven days after the last procedure, upper gastrointestinal contrast studies showed no leaks. The patient was subsequently discharged 9 d after histoacryl injection without any complications.
CONCLUSION To seal an anastomosis leak after stent application, salvage technique using histoacryl injection at the leakage site with fluoroscopy guidance could be considered cautiously.
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Affiliation(s)
- Hee-Sung Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju-si 28644, South Korea
| | - Yook Kim
- Department of Radiology, Chungbuk National University Hospital, Cheongju-si 28644, South Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju-si 28644, South Korea
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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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Rogalski P, Swidnicka-Siergiejko A, Wasielica-Berger J, Zienkiewicz D, Wieckowska B, Wroblewski E, Baniukiewicz A, Rogalska-Plonska M, Siergiejko G, Dabrowski A, Daniluk J. Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis. Surg Endosc 2020; 35:1067-1087. [PMID: 32107632 PMCID: PMC7886733 DOI: 10.1007/s00464-020-07471-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
Background Endoscopic techniques have become the first-line therapy in bariatric surgery-related complications such as leaks and fistulas. We performed a systematic review and meta-analysis on the effectiveness of self-expandable stents, clipping, and tissue sealants in closing of post-bariatric surgery leak/fistula. Methods A systematic literature search of the Medline/Scopus databases was performed to identify full-text articles published up to February 2019 on the use of self-expandable stents, clipping, or tissue sealants as primary endoscopic strategies used for leak/fistula closure. Meta-analysis of studies reporting stents was performed with the PRISMA guidelines. Results Data concerning the efficacy of self-expanding stents in the treatment of leaks/fistulas after bariatric surgery were extracted from 40 studies (493 patients). The overall proportion of successful leak/fistula closure was 92% (95% CI, 90–95%). The overall proportion of stent migration was 23% (95% CI, 19–28%). Seventeen papers (98 patients) reported the use of clipping: the over-the-scope clips (OTSC) system was used in 85 patients with a successful closure rate of 67.1% and a few complications (migration, stenosis, tear). The successful fistula/leak closure using other than OTSC types was achieved in 69.2% of patients. In 10 case series (63 patients), fibrin glue alone was used with a 92.8–100% success rate of fistula closure that usually required repeated sessions at scheduled intervals. The complications of fibrin glue applications were reported in only one study and included pain and fever in 12.5% of patients. Conclusions Endoscopic techniques are effective for management of post-bariatric leaks and fistulas in properly selected patients. Electronic supplementary material The online version of this article (10.1007/s00464-020-07471-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Agnieszka Swidnicka-Siergiejko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland.
| | - Justyna Wasielica-Berger
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Damian Zienkiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Barbara Wieckowska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Rokietnicka 7 St. (1st floor), 60-806, Poznan, Poland
| | - Eugeniusz Wroblewski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Andrzej Baniukiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Magdalena Rogalska-Plonska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Grzegorz Siergiejko
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Jaroslaw Daniluk
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
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De Moura DTH, Baptista A, Jirapinyo P, De Moura EGH, Thompson C. Role of Cardiac Septal Occluders in the Treatment of Gastrointestinal Fistulas: A Systematic Review. Clin Endosc 2020; 53:37-48. [PMID: 31286746 PMCID: PMC7003006 DOI: 10.5946/ce.2019.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/21/2019] [Accepted: 02/24/2019] [Indexed: 02/06/2023] Open
Abstract
Treating gastrointestinal (GI) fistulas endoscopically is challenging owing to an established epithelial tract. The variety of endoscopic approaches is transforming endoscopy into a first-line therapy. However, many sessions are often required, with variable success rates. Owing to these limitations, the off-label use of cardiac septal occluders (CSOs) has been reported. We searched for articles related to CSOs in the MEDLINE, EMBASE, Cochrane Library, and LILACS databases and gray literature. The primary outcomes included technical success, clinical success, and safety of CSOs in GI fistula management. A total of 25,574 records were identified, and 19 studies ultimately satisfied the inclusion criteria. Technical success was achieved in all cases. Of the 22 fistulas, 77.27% had successful closure, with a mean follow-up period of 32.02 weeks. The adverse event rate was 22.72%, with no associated mortality. Univariable and multivariable regression analyses showed no significant difference in the success of closure and adverse events in relation to several variables among the subgroups. The use of CSOs appeared to be technically feasible, effective, and safe in the treatment of GI fistulas. The satisfactory results derived from this sparse literature suggest that it can be an option in the management of GI fistulas.
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Affiliation(s)
- Diogo Turiani Hourneaux De Moura
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Alberto Baptista
- Hospital das Clínicas Caracas, Unidad de Exploraciones Digestivas, Caracas, Venezuela
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Siddiqi S, Schraufnagel DP, Siddiqui HU, Javorski MJ, Mace A, Elnaggar AS, Elgharably H, Vargo PR, Steffen R, Hasan SM, Raja S. Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae. Expert Rev Med Devices 2019; 16:197-209. [PMID: 30767693 DOI: 10.1080/17434440.2019.1582329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
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Affiliation(s)
- Shirin Siddiqi
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Dean P Schraufnagel
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Hafiz Umair Siddiqui
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Michael J Javorski
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Adam Mace
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Abdulrhman S Elnaggar
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert Steffen
- b Department of Cardiovascular Surgery , Minneapolis Heart Institute Foundation , Minneapolis , MN , USA
| | - Saad M Hasan
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Siva Raja
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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Badurdeen DS, Lamond K, Gandsas A, Kumbhari V. Endoscopic strategies for the treatment of postbariatric surgery leaks and fistulas. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Baptista A, Hourneaux De Moura DT, Jirapinyo P, Hourneaux De Moura EG, Gelrud A, Kahaleh M, Salinas A, Sabagh LC, Ospina A, Rincones VZ, Doval R, Bandel JW, Thompson CC. Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas. Gastrointest Endosc 2019; 89:671-679.e1. [PMID: 30529441 DOI: 10.1016/j.gie.2018.11.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopy has evolved to become first-line therapy for the treatment of post-bariatric leaks; however, many sessions are often required with variable success rates. Due to these limitations, the use of the cardiac septal defect occluder (CSDO) has recently been reported in this population. METHODS The study population was a multicenter retrospective series of patients with post-bariatric surgical leaks who underwent treatment with CSDO placement. Data on the type of surgery, previous treatment details, fistula dimensions, success rate, and adverse events were collected. Leaks were grouped according to the International Sleeve Gastrectomy Expert Panel Consensus. Outcomes included technical and clinical success and safety of the CSDO. Regression analysis was performed to determine the predictors of response. RESULTS Forty-three patients with leaks were included (31 sleeve gastrectomy and 12 Roux-en-Y gastric bypass). They were divided into acute (n = 3), early (n = 5), late (n = 23), and chronic (n = 12). Forty patients had failed previous endoscopic treatment and 3 patients had CSDO as the primary treatment. Median follow-up was 34 weeks. Technical success was achieved in all patients and clinical success in 39 patients (90.7%). All chronic, late, and early leaks were successfully closed, except one undrained late leak. The 5 patients with early leaks had an initial satisfactory response, but within 30 days, drainage recurred. The CSDOs were removed and replaced with larger-diameter devices leading to permanent defect closure. Acute leaks were not successfully closed in all 3 patients. Regression analysis showed that chronicity and previous treatment were associated with fistula closure; success rates for late/chronic leaks versus acute/early leaks were 97.1% and 62.5%, respectively (P = .0023). CONCLUSION This observational study found that the CSDO had a high efficacy rate in patients with non-acute leaks, with no adverse events. All early, late, and chronic leaks were successfully closed, except for one undrained late leak. However, early leaks required a second placement of a larger CSDO in all cases. These results suggest that the CSDO should be considered for non-acute fistula and that traditional closure methods are likely preferred in the acute and early settings.
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Affiliation(s)
- Alberto Baptista
- Hospital das Clínicas Caracas, Unidad de Exploraciones Digestivas, Caracas, Venezuela
| | - Diogo Turiani Hourneaux De Moura
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Pichamol Jirapinyo
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Michel Kahaleh
- Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Alberto Salinas
- Hospital das Clínicas Caracas, Unidad de Exploraciones Digestivas, Caracas, Venezuela
| | | | | | | | - Raul Doval
- Centro Médico de Caracas, Caracas, Venezuela
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Abstract
PURPOSE OF REVIEW Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects. RECENT FINDINGS The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.
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EUS-Guided Drainage of Post-operative Subphrenic Fluid Collection Through Gastric Pouch with a Lumen-Apposing Metal Stent in a Patient with Roux-en-Y Gastric Bypass. Obes Surg 2018; 28:3301-3303. [DOI: 10.1007/s11695-018-3422-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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18
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Role of Percutaneous Glue Treatment After Persisting Leak After Laparoscopic Sleeve Gastrectomy. Obes Surg 2017; 26:1378-83. [PMID: 26572526 DOI: 10.1007/s11695-015-1959-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Over the years, many treatment modes have been attempted for gastrocutaneous fistula (GCF) after laparoscopic sleeve gastrectomy (LSG). Minimally invasive techniques for GCF treatment include stent placement and radiological percutaneous glue treatment (GT). MATERIAL AND METHOD Ten patients underwent a radiological acrylate mixed with contrast medium GT combined or not with other treatment strategies such as relaparoscopy, ultrasound, or computerized tomography scan (CT scan)-guided drain and endoscopic stent placement. RESULTS Ten patients (mean age 47.1 years, range 64-29) were treated by percutaneous injection of glue after LSG leak. Body mass index (BMI) was 42.2 kg/m(2) ± 6.7 at the time of LSG surgery. Mean time between LSG and leak diagnosis was 12 days (range 4-31 days). GT was only effective when performed after endoscopic stent placement (80 % resolution). With this regimen, five patients required a laparoscopic Roux limb placement. All fistulas eventually healed a mean of 75 days (range 29-293 days) after GCF diagnosis. CONCLUSIONS Percutaneous glue treatment alone does not seem to provide adequate results. Stenting previous to the glue treatment allows for better results.
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20
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Schulman AR, Thompson CC. Complications of Bariatric Surgery: What You Can Expect to See in Your GI Practice. Am J Gastroenterol 2017; 112:1640-1655. [PMID: 28809386 DOI: 10.1038/ajg.2017.241] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023]
Abstract
Obesity is one of the most significant health problems worldwide. Bariatric surgery has become one of the fastest growing operative procedures and has gained acceptance as the leading option for weight-loss. Despite improvement in the performance of bariatric surgical procedures, complications are not uncommon. There are a number of unique complications that arise in this patient population and require specific knowledge for proper management. Furthermore, conditions unrelated to the altered anatomy typically require a different management strategy. As such, a basic understanding of surgical anatomy, potential complications, and endoscopic tools and techniques for optimal management is essential for the practicing gastroenterologist. Gastroenterologists should be familiar with these procedures and complication management strategies. This review will cover these topics and focus on major complications that gastroenterologists will be most likely to see in their practice.
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Affiliation(s)
- Allison R Schulman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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21
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Jirapinyo P, Thompson CC. Training in bariatric endoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Devaraj P, Gavini H. Endoscopic management of postoperative fistulas and leaks. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Prathab Devaraj
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
| | - Hemanth Gavini
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
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Shehab HM, Hakky SM, Gawdat KA. An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video). Obes Surg 2016; 26:941-8. [PMID: 26464242 DOI: 10.1007/s11695-015-1857-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic stenting has proved effective in the management of post-surgical leaks but is strongly hampered by the high rate of stent migration. In this study, we evaluate our experience with a new approach involving the use of novel ultra-large expandable stents tailored for bariatric surgery leaks (Mega stents), combined with the use of the innovative over-the-scope clips (OTSC). METHODS Retrospective analysis of patients with post-bariatric surgery leaks managed at our institution by an approach combining Mega stents and over-the-scope clips. RESULTS Twenty-two patients were treated for post-bariatric surgery leaks; 13 (59%) had a sleeve gastrectomy while nine (41%) had a RYGB. A total of 30 stents were inserted. Successful endoscopic insertion and removal were achieved in all patients. OTSC clips were applied in 12 patients (55%); five simultaneously with stents and seven after stent removal. Primary closure (after one endoscopic procedure) was achieved in 13 patients (59%) and in a total of 18 patients after multiple endoscopic procedures (82%). An average of 1.4 stents and 2.8 endoscopic procedures were required per patient. Stent migration occurred in four patients (18%), and all were retrievable endoscopically. Other complications included retrosternal pain and vomiting in 20 patients (91%) including one necessitating early removal, bleeding in two patients (9%), and perforation and esophageal stricture in one patient each (5%). Two mortalities were encountered, and one of them was stent-related (bleeding). CONCLUSION Mega stents are effective in the management of post-bariatric surgery leaks. The combined use of Mega stents and OTSC clips is associated with a low incidence of migration and a low number of stents and procedures required per patient.
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Affiliation(s)
- Hany M Shehab
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt.
| | - Sherif M Hakky
- Bariatric Surgery Department, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt
| | - Khaled A Gawdat
- General Surgery Department, Ain Shams University Hospital, Ain Shams University, Cairo, Egypt
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Boules M, Chang J, Haskins IN, Sharma G, Froylich D, El-Hayek K, Rodriguez J, Kroh M. Endoscopic management of post-bariatric surgery complications. World J Gastrointest Endosc 2016; 8:591-599. [PMID: 27668069 PMCID: PMC5027029 DOI: 10.4253/wjge.v8.i17.591] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/02/2016] [Accepted: 07/22/2016] [Indexed: 02/05/2023] Open
Abstract
Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early (< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late (> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.
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25
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Niland B, Brock A. Over-the-scope clip for endoscopic closure of gastrogastric fistulae. Surg Obes Relat Dis 2016; 13:15-20. [PMID: 27693362 DOI: 10.1016/j.soard.2016.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 06/02/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastrogastric fistulae (GGF) are a well-known complication of Roux-en-Y gastric bypass (RYGB). Endoscopic approaches for closure of GGF have gained popularity, but with limited data and efficacy. OBJECTIVES The primary arm of the study was to evaluate the safety and efficacy of the endoscopic closure of GGF using the over-the-scope clip (OTSC) device. SETTING University hospital, United States METHODS: This is a retrospective review of consecutive patients at a single academic center from September 2013 to December 2014 who underwent upper endoscopy with attempted OTSC placement for closure of GGF related to RYGB. Preprocedural, procedural, and postprocedural data were collected. Outcome measures included technical success, primary success, and long-term success. RESULTS A total of 14 patients underwent attempted GGF closure using OTSC. Twelve of the 14 patients (85.7%) had technical success. Four patients were lost to follow-up. Primary success was achieved in 5 of the 10 patients (50%) in which it was assessed, either by upper gastrointestinal series or endoscopy. One of the 5 patients who had primary success was then lost to follow-up. Of the 4 patients in whom primary success was achieved and had long-term follow up, 75% (n = 3) achieved long-term success at a mean follow-up of 6.6 months from initial OTSC placement (range, 3-9), making for a long-term success rate of 33% (3/9). There were no reported complications. CONCLUSION OTSC closure of small GGF is feasible, safe, and offers a reasonable alternative to surgical revision. Large GGF may undergo attempted endoscopic closure, acknowledging a high failure rate.
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Affiliation(s)
- Benjamin Niland
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Andrew Brock
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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Malli CP, Sioulas AD, Emmanouil T, Dimitriadis GD, Triantafyllou K. Endoscopy after bariatric surgery. Ann Gastroenterol 2016; 29:249-257. [PMID: 27366025 PMCID: PMC4923810 DOI: 10.20524/aog.2016.0034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/08/2016] [Indexed: 12/16/2022] Open
Abstract
Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.
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Affiliation(s)
- Chrysoula P. Malli
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Athanasios D. Sioulas
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Theodoros Emmanouil
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - George D. Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
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27
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Shehab H. Endoscopic management of postsurgical leaks. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Hany Shehab
- Gastrointestinal Endoscopy Unit, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt
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28
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Donatelli G, Dumont JL, Cereatti F, Ferretti S, Vergeau BM, Tuszynski T, Pourcher G, Tranchart H, Mariani P, Meduri A, Catheline JM, Dagher I, Fiocca F, Marmuse JP, Meduri B. Treatment of Leaks Following Sleeve Gastrectomy by Endoscopic Internal Drainage (EID). Obes Surg 2016; 25:1293-301. [PMID: 25913755 DOI: 10.1007/s11695-015-1675-x] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks. METHODS Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing. RESULTS Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically. CONCLUSIONS EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.
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Affiliation(s)
- G Donatelli
- Unité d'Endoscopie Interventionnelle, Générale de Santé, Hôpital Privé des Peupliers, 8 Place de l'Abbé G. Henocque, 75013, Paris, France,
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Clinical Outcomes of Postoperative Upper Gastrointestinal Leakage According to Treatment Modality. Dig Dis Sci 2016; 61:523-32. [PMID: 26537488 DOI: 10.1007/s10620-015-3880-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 09/10/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIM We evaluated the clinical outcomes according to treatment modality for gastrointestinal anastomotic leakage. METHODS Of the 19,207 patients who underwent gastrectomy for gastric cancer from March 2000 to April 2013, we retrospectively analyzed the 133 cases who developed anastomotic leakage. These patients were treated using endoscopic management, surgery, or conservative management (endoscopic treatment was introduced in 2009). To evaluate the efficacy of endoscopic treatment, we compared the clinical outcomes between the conservative management-only group before 2009 and the conservative or endoscopic management group from 2009; and between the surgical management-only group before 2009 and the surgical or endoscopic management group from 2009. RESULTS Seventy-three were initially managed conservatively, 35 were treated surgically, and 25 were treated using endoscopic procedures. Chronologically comparing each treatment group as 'before 2009' (n = 54) and 'from 2009' (n = 79), there were differences in the length of hospital stay (median 32 versus 27, p = 0.048) and duration of antibiotic use (median 28 versus 20, p = 0.013). Patients who underwent conservative or endoscopic management from 2009 showed a shorter hospital stay, period of fasting, and duration of antibiotic use than patients who underwent only conservative management before 2009. Patients who received surgery or endoscopic management from 2009 showed a shorter hospital stay and duration of antibiotic use than patients who underwent only surgery before 2009. CONCLUSION Endoscopic management for selected cases can reduce duration of hospital stay and antibiotic administration in the treatment of anastomotic leakage after gastrectomy.
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Eisendrath P, Deviere J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol 2015; 12:701-10. [PMID: 26347162 DOI: 10.1038/nrgastro.2015.151] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Leaks are the most frequent early postoperative complication in the two most popular bariatric procedures, Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy. Multimodal therapy based on self-expandable stent insertion 'to cover' the defect is the most widely documented technique to date with a reported success rate >80%. Additional experimental techniques 'to close' the defect or 'to drain' the paradigestive cavity have been reported with encouraging results. The role of endoscopy in early postoperative bleeding is limited to management of bleeds arising from fresh sutures and the diagnosis of chronic sources of bleeding such as marginal ulcer after RYGB. Post-RYGB stricture is a more delayed complication than leaks and the role of endoscopic dilation as a first-line treatment in this indication is well documented. Ring and band placement are outdated procedures for obesity treatment, but might still be an indication for endoscopic removal, a technique which does not compromise further surgery, if needed.
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Affiliation(s)
- Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Jacques Deviere
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
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Willingham FF, Buscaglia JM. Endoscopic Management of Gastrointestinal Leaks and Fistulae. Clin Gastroenterol Hepatol 2015; 13:1714-21. [PMID: 25697628 DOI: 10.1016/j.cgh.2015.02.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 02/04/2015] [Accepted: 02/05/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal leaks and fistulae can be serious acute complications or chronic morbid conditions resulting from inflammatory, malignant, or postsurgical states. Endoscopic closure of gastrointestinal leaks and fistulae represents major progress in the treatment of patients with these complex presentations. The main goal of endoscopic therapy is the interruption of the flow of luminal contents across a gastrointestinal defect. In consideration of the proper endoscopic approach to luminal closure, several basic principles must be considered. Undrained cavities and fluid collections must often first be drained percutaneously, and the percutaneous drain provides an important measure of safety for subsequent endoscopic luminal manipulations. The size and exact location of the leak/fistula, as well as the viability of the surrounding tissue, must be defined. Almost all complex leaks and fistulae must be approached in a multidisciplinary manner, collaborating with colleagues in nutrition, radiology, and surgery. Currently, gastrointestinal leaks and fistulae may be managed endoscopically by using 1 or more of the following modalities: stent placement, clip closure (including through-the-scope clips and over-the-scope devices), endoscopic suturing, and the injection of tissue sealants. In this article, we discuss these modalities and review the published outcomes data regarding each approach as well as practical considerations for successful closure of luminal defects.
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Affiliation(s)
- Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| | - Jonathan M Buscaglia
- Division of Gastroenterology, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York
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Abstract
PURPOSE OF REVIEW Bariatric surgery is recognized as the most effective treatment against obesity as it results in significant weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. This review illustrates the latest developments in the endoscopic management of bariatric surgical complications. RECENT FINDINGS For successful management of complications, precipitating and perpetuating factors must be addressed in addition to directing therapy at the target pathology. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Chronic proximal staple-line leaks/fistulas frequently do not respond to primary closure with diversion therapy, and a new technique of stricturotomy has been reported to improve outcomes. Innovations in the field of transoral endoscopic instruments have led to the development of a single-session entirely internal endoscopic retrograde cholangiopancreatography by creating a gastrogastric anastomosis. SUMMARY Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention. Computed tomography-guided drainage may be necessary in patients with drainable fluid collections. VIDEO ABSTRACT http://links.lww.com/COG/A11.
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Singhal S, Changela K, Culliford A, Duddempudi S, Krishnaiah M, Anand S. Endoscopic closure of persistent gastrocutaneous fistulae, after percutaneous endoscopic gastrostomy (PEG) tube placement, using the over-the-scope-clip system. Therap Adv Gastroenterol 2015; 8:182-8. [PMID: 26136836 PMCID: PMC4480569 DOI: 10.1177/1756283x15578603] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES The Over-The-Scope-Clip (OTSC) has had an evolving role in endoscopic closure of gastrointestinal wall defects, in hemostasis of primary or postinterventional bleeding, and approximation of postbariatric surgery defects. Rapid and effective closure of gastrocutaneous (GC) fistulae using this device has been recently described in the literature. The aim of this study was to evaluate the technical feasibility, efficacy and safety of OTSC as an effective tool in the management of persistent GC fistulae secondary to a complication of percutaneous endoscopic gastrostomy (PEG) tube placement. METHOD In this multicenter prospective observational study, we describe our experience with OTSC in the closure of persistent GC fistulas secondary to PEG tube placement. Patients with GC fistulas were sequentially enrolled with a mean age of 84 years. Primary treatment outcome was the immediate successful closure of GC fistula and resolution of leak. Secondary outcome was no recurrence of the fistula and leaks on follow up. RESULTS A total of 10 patients were enrolled over the study period. Mean age was 84.4 ± 8.75 years. The primary treatment outcome was achieved in all the patients undergoing this intervention. Secondary outcome was observed in 9/10 (90%) subjects. No procedural complications were reported. Larger fistulae (>2.5 cm) and those with significant fibrosis were more difficult to close with the OTSC system. The mean follow-up time after OTSC application was 43.7 ± 20.57 days. A limitation of this study was that there was no control group. CONCLUSIONS OTSC application is a safe and effective endoscopic approach for the closure of persistent GC fistulae secondary to a complication of PEG tube placement.
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Affiliation(s)
- Shashideep Singhal
- Division of Gastroenterology, The Brooklyn Hospital Center, New York Presbyterian Healthcare System, 121 Dekalb Ave, Brooklyn, NY 11201, USA
| | - Kinesh Changela
- Division of Gastroenterology, The Brooklyn Hospital Center, New York Presbyterian Healthcare System, Brooklyn NY, USA
| | - Andrea Culliford
- Division of Gastroenterology, St Barnabas Hospital, Bronx, NY, USA
| | - Sushil Duddempudi
- Division of Gastroenterology, The Brooklyn Hospital Center, New York Presbyterian Healthcare System, Brooklyn NY, USA
| | - Mahesh Krishnaiah
- Division of Gastroenterology, The Brooklyn Hospital Center, New York Presbyterian Healthcare System, Brooklyn NY, USA
| | - Sury Anand
- Division of Gastroenterology, The Brooklyn Hospital Center, New York Presbyterian Healthcare System, Brooklyn NY, USA
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Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Pasha SF, Saltzman JR, Shaukat A, Wang A, Stefanidis D, Richardson WS, Kothari SN, Cash BD. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 2015; 81:1063-1072. [PMID: 25733126 DOI: 10.1016/j.gie.2014.09.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/11/2014] [Indexed: 12/22/2022]
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Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Pasha SF, Saltzman JR, Shaukat A, Wang A, Stefanidis D, Richardson WS, Khothari SN, Cash BD. The role of endoscopy in the bariatric surgery patient. Surg Obes Relat Dis 2015; 11:507-517. [PMID: 26093766 DOI: 10.1016/j.soard.2015.02.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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ASGE STANDARDS OF PRACTICE COMMITTEE. The role of endoscopy in the bariatric surgery patient. Surg Endosc 2015; 29:1007-1017. [PMID: 26038784 DOI: 10.1007/s00464-015-4111-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Endoscopic closure of gastric tube perforations with titanium clips: a four-case report. World J Surg Oncol 2015; 13:25. [PMID: 25889662 PMCID: PMC4336678 DOI: 10.1186/s12957-015-0434-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 01/05/2015] [Indexed: 01/30/2023] Open
Abstract
Perforation of a gastric tube is a rare yet lethal complication after esophagectomy for esophageal cancer treatment. Currently, over-the-scope clip (OTSC) is an effective way to treat gastric tube perforation. Due to the lack of OTSCs, we invented an alternative method composed of a titanium clip and gastroscope. The aim of this study was to describe this novel endoscopic device in the treatment of gastric tube perforation. We used a titanium clip system to treat 4 male patients (range, 53 to 77 years with gastric tube perforation. After the location of the perforation was identified by gastroscope, a titanium endoscopic clip was used to close the perforation. Successful closure of the gastric tube perforation was achieved in three patients while in one patient this failed due to his refusal to undergo reoperation. No postoperative complication was found in the three patients whose perforations were closed and the patient who refused reoperation died due to the reoccurrence of his esophago-cardiac carcinoma. The endoscopic system composed of titanium clip and gastroscope proved to be an efficient and effective device in the treatment of the patients with gastric tube perforations.
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Kotzampassi K, Eleftheriadis E. Tissue sealants in endoscopic applications for anastomotic leakage during a 25-year period. Surgery 2015; 157:79-86. [PMID: 25444220 DOI: 10.1016/j.surg.2014.06.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leakage after gastrointestinal operation is a complication difficult to manage because conservative therapy and/or reoperation may be unsuccessful and carry the risk of increased morbidity and mortality. The endoscopic use of tissue sealants appears to be a promising alternative to avoid operation. METHOD We present conclusively our 25-year experience with tissue sealing in a series of 63 patients referred after gastrointestinal anastomosis leakage; 48 of the upper and 15 of the lower gastrointestinal tract, experiencing a drainage volume ranging 50-2,400 mL. RESULTS Tissue glue was applied orally in 37, anally in 10, through the fistula tract in 8, and through a combination of approximation routes in another 8 cases. Biological glue (fibrin) was used in 47, cyanoacrylate in 8, and both glue types in another 8 patients. The total volume of fibrin applied was 2-36 mL, in a median of four sessions, 0.5-4 mL for cyanoacrylate, in a median of two sessions, and, whenever a combination of glues was used, a volume of 12-40 mL of fibrin plus 1-4 mL of cyanoacrylate, in a median of nine sessions. The median hospital stay after initiation of gluing was 14 days (range 8-32). The clinical and technical success rate was 96.8% (61 of 63 patients). CONCLUSION Tissue glue appears to be a valuable clinical tool that would prevent further operative interventions and the associated morbidity and mortality after a gastrointestinal anastomosis dehiscence. However, it must be borne in mind that repeated sessions and large volumes of sealants are necessary in many cases.
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Affiliation(s)
- Katerina Kotzampassi
- Department of Surgery, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymios Eleftheriadis
- Department of Surgery, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Double-type metallic stents efficacy for the management of post-operative fistulas, leakages, and perforations of the upper gastrointestinal tract. Surg Endosc 2014; 29:2013-8. [PMID: 25303919 DOI: 10.1007/s00464-014-3904-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 09/08/2014] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The management of post-operative anastomotic leakage and fistulas of the upper GI tract remains challenging. Fully covered stents are used despite a high risk of migration because of a better removability. The goal of our study was to evaluate the effectiveness of this new type of endoscopic stent in this indication. The secondary objective was to determine the ability of withdrawing this stent. METHODS Thirty-six patients treated for upper GI fistula using a double-type metallic stent (DTMS) (Taewoong, Korea) for a benign indication were included in this retrospective study. This stent associates an outer uncovered metallic stent, decreasing the risk of migration, to an inner fully covered stent that ensured its tightness. The DTMS was removed after 4 weeks of treatment. RESULTS Twenty-four patients had a post-operative fistula (15 sleeve gastrectomies), eight had an anastomotic leakage, and four had an esophageal perforation. Seventeen patients underwent a previous failed stenting, and fourteen had an associated treatment with OTSC clips. A final complete healing was achieved in twenty-six patients (72%). For patients with fistulas, the overall success rate was 66.6% (16/24) mostly in case of post sleeve fistula (80%), and it was 75% (6/8) for patients with anastomotic leakages (3/4). We reached a primary success (one session) in twenty-one cases (58.3%), and a second session was required in five cases. All the stents were removed without complications after a median stenting time of 32 [20-71] days. The spontaneous migration rate was 16.6%. CONCLUSION This new double-type stent is a new and efficient way to treat post-operative fistulas and leakages in the upper GI tract. The stents were always removable despite the external uncovered part with a low migration rate.
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Sharata A, Bhayani NH, Dunst CM, Kurian AA, Reavis KM, Swanström LL. Gastro-bronchial fistula closed by endoscopic fistula plug (with video). Surg Endosc 2014; 28:3500-4. [PMID: 24993168 DOI: 10.1007/s00464-014-3631-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/21/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fistulae between the tracheobronchial tree and the gastric conduit post-esophagectomy are a rare but sometimes fatal complication. Clinical presentation can range from asymptomatic to acute pulmonary decompensation. Traditional management options, such as esophageal exclusion alone or combined with transthoracic fistula division, and closure (with tissue interposition), are highly invasive, technically difficult, and associated with variable success rates. This video presents closure of highly complex, chronic esophagobronchial fistula (EBF) using simultaneous bronchoscopic and upper endoscopic techniques. METHODS Diagnostic bronchoscopy and upper endoscopy are performed to assess the size and location of fistulae. Fistulae with sufficient luminal size to accommodate a biologic plug were selected for treatment. Steps of EBF plug insertion. (1) Wire across fistula with ends exposed through the mouth. (2) Delivery sheath passed across wire from bronchial side to esophageal side (3) Plug loaded on the esophageal side of the sheath. (4) Plug pulled into position across the fistula from esophageal to bronchial side. (5) Delivery sheath released from bronchial side. RESULTS Two of four fistulae were suitable for plug therapy. A temporary covered-stent was placed to help maintain the plugs in place. Endoscopy at 1 month showed healing of the plugged fistula following stent removal. Respiratory symptoms were improved with no further episodes of pneumonia. Over course of 2 years, the patient has required three additional endoscopic procedures to control new fistulae from this broad area of exposed lung paranchyma, but the initial fistula plug repair is durable. CONCLUSION Post-esophagectomy fistula is a morbid complication and the surgical treatments available are highly morbid and have variable success rates. Due to the development of new endoscopic technologies, the endotherapy has assumed new prominence for treatment of enteric fistula. This complex case illustrates feasibility of endoscopic fistula treatment using dual scope, biologic plug application which effectively controlled this patient's EBF symptoms.
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Affiliation(s)
- Ahmed Sharata
- Providence Portland Cancer Center, 4805 NE Glisan Street, #6N60, Portland, OR, 97213, USA,
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Landmann RG. Surgical management of anastomotic leak following colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature. Obes Surg 2014; 23:1692-7. [PMID: 23912265 DOI: 10.1007/s11695-013-1048-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly performed bariatric/metabolic operation in Europe. Different treatment options for the management of gastrojejunal (GJ) leaks following LRYGB have been published. We looked at our own experience with GJ leaks after 645 consecutive LRYGB operations and reviewed the literature with focus on the use of fibrin sealant and self-expandable metal stents as treatment options. Patient data were prospectively collected in the hospital's database for bariatric patients. All patients with confirmed GJ leaks were reviewed. Patients with GJ leaks were actively treated by a combination of laparoscopic drainage and endoscopic fibrin sealant injections and/or stenting. Six patients (0.93%) have been treated for GJ leaks. All leaks were successfully treated and there was no leak-related mortality. The mean (SD) time for closure of the leaks and length of hospital stay was 19.5 days (6.2) and 23.2 days (3.7). The literature concerning endoscopic treatment options in case of GJ leaks following LRYGB operations is scarce and inconclusive. Immediate and active treatment with a combination of operative and endoscopic treatment options, rather than choosing only one treatment over another, may enhance the recovery process.
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Ritter LA, Wang AY, Sauer BG, Kleiner DE. Healing of complicated gastric leaks in bariatric patients using endoscopic clips. JSLS 2014; 17:481-3. [PMID: 24018092 PMCID: PMC3771774 DOI: 10.4293/108680813x13693422521999] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Endoscopists have used clipping devices to successfully close acute, iatrogenic perforations throughout the gastrointestinal tract. We applied this technology to our bariatric patients, who tend to present with a more delayed anastomotic leak, to determine whether these leaks and fistulae would also heal with endoclip application. CASE DESCRIPTION We describe a small series of 2 clinically stable bariatric patients who presented with postoperative anastomotic leaks who met criteria for non-operative therapy. The first underwent a laparoscopic Roux-en-Y gastric bypass and presented postoperatively with a leak at her gastrojejunal anastomosis. The location was not amenable to stent placement; therefore, 2 endoclips were placed. The leak was sealed by fluoroscopic examination 14 d later. The second had a reversal of a previous gastric bypass, creating a new gastrogastric anastomosis. A leak was found at this new connection postoperatively. After failure of a stent to seal the leak, 8 endoclips were used. This patient also had successful closure of her leak on fluoroscopy 14 d postprocedure. DISCUSSION Anastomotic leaks after bariatric surgery can incur severe morbidity, cost, and detriment to patients' quality of life. Unstable patients require operative intervention. Stable patients are candidates for more-conservative measures. Endoscopic stents have been successful in closing gastric leaks, though some are not anatomically amenable to stent placement, and stents also have the potential to migrate distally. We demonstrate 2 cases of successful closure of leaks in bariatric patients by using endoclips and suggest that this be considered an option in appropriate cases.
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Affiliation(s)
- Lane A Ritter
- Department of General Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Correia T, Amaro P, Sofia C. Tratamento de deiscência cirúrgica grave com sistema «Over-the-scope clip». ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.jpg.2013.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abulfaraj M, Mathavan V, Arregui M. Therapeutic flexible endoscopy replacing surgery: Part 1—Leaks and fistulas. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2013. [DOI: 10.1016/j.tgie.2013.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Bariatric surgery is the most effective treatment for the medical comorbidities associated with morbid obesity. Though uncommon, staple line or anastomotic leaks after bariatric surgery are highly morbid events and challenging to treat. In selected patients without severe sepsis or distant pollution, endoscopic transluminal peritoneal drainage may provide source control. For leaks within 3 days of surgery, endoscopic stenting does not appear to speed closure but does permit oral nutrition. In uncomplicated situations, the risk of migration and resulting complications of enteric stents appear to overshadow the benefits. Initial treatment failures and leaks presenting more than 48 hours after surgery respond to enteric diversion by endoscopic stenting. Occlusion of the leak by injection of fibrin glue also shows promise; however, these case series are limited to a small number of patients. Endoclips may work best to occlude leaks and close fistulas if the epithelium is debrided. As suturing technology improves, direct internal closure of fistulas may prove feasible. Therapeutic endoscopy offers several technologies that can assist in the closure of early leaks and that are essential to the treatment of late leaks and fistulas after bariatric surgery.
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Abstract
Endoscopy has an ever-increasing role in the treatment of complications in digestive surgery. Endoscopic treatment is essentially used for (i) fistula or intra-abdominal collection secondary to anastomotic dehiscence and (ii) anastomotic stricture, especially esophagogastric, but also sometimes after colorectal surgery. First intention treatment of fistula following esophagogastric surgery is the insertion of an extractable self-expandable metallic stent (partially or entirely covered); this is supported by a low level of scientific evidence, but clinical experience has been satisfactory. Other techniques for treatment of anastomotic leak have also been reported anecdotally (clip placement, sealing with glue). There are few data available in the literature on endoscopic management (stents essentially) of postoperative colonic fistula. Whatever the approach chosen to treat a postoperative digestive tract fistula, management is medico-surgical and cannot be limited to simple closure of the digestive tube wall defect. Drainage of any collections by endoscopic, radiologic or surgical approach, systemic treatment of infection and nutritional support are essential adjuvant treatment modalities. Treatment of postoperative esophageal or colonic strictures is essentially endoscopic and is based on initial dilatation (endoscopic with hydrostatic balloon or bougie), and placement of extractable metallic stents (partially or entirely covered) in case of refractory outcome.
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Affiliation(s)
- X Dray
- Université Paris Diderot, Paris 7, AP-HP, Service d'Hépatogastroentérologie, Hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
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Shehab HM, Elasmar HM. Combined endoscopic techniques for closure of a chronic post-surgical gastrocutaneous fistula: case report and review of the literature (with video). Surg Endosc 2013; 27:2967-70. [PMID: 23436089 DOI: 10.1007/s00464-013-2839-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 01/16/2013] [Indexed: 01/19/2023]
Abstract
Several techniques have been proposed to seal post-operative leaks endoscopicaly, however, chronic fibrosed fistulas remain a tenacious problem. We describe the success of a combination of minimally invasive peroral endoscopic techniques to seal and permanently close a chronic gastrocutaneous fistula complicating a laparoscopic gastric bypass, these techniques included: fistuloscopy, argon plasma coagulation, mucosal stripping and the novel over-the-scope clips.
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Affiliation(s)
- Hany M Shehab
- Gastroenterology Department, Dar Alfouad Hospital, 26th of July St., 6th of October City, Giza 12568, Egypt.
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Kim YJ, Shin SK, Lee HJ, Chung HS, Lee YC, Park JC, Hyung WJ, Noh SH, Kim CB, Lee SK. Endoscopic management of anastomotic leakage after gastrectomy for gastric cancer: how efficacious is it? Scand J Gastroenterol 2013; 48:111-118. [PMID: 23116156 DOI: 10.3109/00365521.2012.737362] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anastomotic leak is a dreadful complication with a high mortality rate. The authors aimed to evaluate the efficacy of endoscopic closure of anastomotic dehiscence after gastrectomy in patients with gastric cancer. METHODS The authors retrospectively reviewed 33 patients with anastomotic leakage who had underdone endoscopic treatment among 5249 patients with gastric cancer who underwent radical total or subtotal gastrectomy. Methods of endoscopic closure included clipping with or without detachable snare, fibrosealant, Histoacryl® or stent insertion. Results of endoscopic treatment were categorized as complete, partial closure and failure. RESULTS The size of the tissue defect was the only factor that had statistically significant differences among the cases with complete closure, partial closure and failure (p = 0.005). For tissue defects smaller than 2 cm in size, complete closure was achieved in 19 (73.1%), partial closure in 5 patients (19.2%) and 2 failed (7.6%). For those larger than 2 cm in size, one (14.3%) was completely closed, four (57.1%) were partially closed and two (28.6%) failed. CONCLUSIONS Endoscopic treatment for anastomotic dehiscence smaller than 2 cm in size had excellent success rate in this study.
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Affiliation(s)
- Yu Jin Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
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El Mourad H, Himpens J, Verhofstadt J. Stent treatment for fistula after obesity surgery: results in 47 consecutive patients. Surg Endosc 2012; 27:808-16. [PMID: 23052499 DOI: 10.1007/s00464-012-2517-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 07/03/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery. METHODS We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications. RESULTS There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment. CONCLUSIONS Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.
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Affiliation(s)
- Haicam El Mourad
- Obesity Surgery Department, AZ St. Blasius Hospital, 50 Kroonveldlaan, 9200 Dendermonde, Belgium.
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