Percutaneous gastric remnant gastrostomy following Roux-en-Y gastric bypass surgery: a single tertiary center's 13-year experience

Iatrogenic vascular complications of non-vascular percutaneous abdominal procedures

PURPOSE

The purpose of this paper is to compile and present all of the reported vascular complications that resulted from common non-vascular abdominal procedures in the literature. Non-vascular procedures include, though are not limited to, percutaneous abscess/fluid collection drainage (PAD), percutaneous nephrostomy (PN), paracentesis, percutaneous transhepatic cholangiography (PTC)/percutaneous biliary drainage (PBD), percutaneous biliary stone removal, and percutaneous radiologic gastrostomy (PG)/percutaneous radiologic gastrojejunostomy (PG-J). By gathering this information, radiologists performing these procedures can be aware of the associated vascular injuries, as well as take steps to minimize risks.

METHODS

A literature review was conducted using the PubMed database to catalog relevant articles, published in the year 2000 onward, in which an iatrogenic vascular complication occurred from the following non-vascular abdominal procedures: PAD, PN, paracentesis, PTC/PBD, percutaneous biliary stone removal, and PG/PG-J. Biopsy and tumor ablation were deferred from this article.

RESULTS

214 studies met criteria for analysis. 28 patients died as a result of vascular complications from the analyzed non-vascular abdominal procedures. Vascular complications from paracentesis were responsible for 19 patient deaths, followed by four deaths from PTC/PBD, three from biliary stone removal, and two from PG.

CONCLUSION

Despite non-vascular percutaneous abdominal procedures being minimally invasive, vascular complications still can arise and be quite serious, even resulting in death. Through the presentation of vascular complications associated with these procedures, interventionalists can improve patient care by understanding the steps that can be taken to minimize these risks and to reduce complication rates.

Nonhepatic hyperammonemic encephalopathy following bariatric surgery: A systematic review

BACKGROUND

Nonhepatic Hyperammonemic encephalopathy (NHAE) following Bariatric Surgery (BS), mainly Roux-en-Y Gastric Bypass (RYGB) and Biliopancreatic Diversion (BPD) is a potentially devastating condition if not diagnosed and managed promptly.

METHODS

A literature review was performed using PRISMA guidelines. Eighteen studies and 3 conference abstracts with a total of 33 patients were included in this review.

RESULTS

Majority (28 patients, 84.8 %) had RYGB. Seven patients (21.2 %) had associated metabolic disorders. 60 % of patients presented with neurological symptoms or signs such as confusion, cognitive and/or psychomotor changes, and decreased reflexes. Two patients presented with status epilepticus. In 30 of the 33 patients an elevated serum ammonia levels was reported (90.9 %). The overall mortality was 39.3 %.

CONCLUSION

NHAE is a rare condition following bariatric surgery (in particular bypass procedures), carrying a high mortality rate. The signs and symptoms are predominantly neurological and may be mistaken for Wernicke's encephalopathy or other more common neurological conditions. Serum ammonia levels should be checked in those who present with these symptoms and signs. Prompt treatment might be life saving in patients with NHAE.

Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study

BACKGROUND AND AIMS

EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure.

METHODS

This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon.

RESULTS

Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%).

CONCLUSIONS

Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.

Relief of malignant gastric outlet obstruction with lumen-apposing metallic stent-assisted percutaneous endoscopic gastrostomy tube after Roux-en-Y gastric bypass

Video 1Xxx.

EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience

BACKGROUND AND AIMS

Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs.

METHODS

This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management.

RESULTS

Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically.

CONCLUSIONS

EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.

Laparoscopic Insertion of a Percutaneous Gastrostomy Prevented Malnutrition in a Patient with Previous Roux-en-Y Gastric Bypass

Bariatric surgery is a highly effective treatment option for morbid obesity. Short- and long-term effects of bariatric surgery are not limited to weight loss but include resolution of type 2 diabetes, arterial hypertension, improvement of cardiovascular health, and overall mortality. The long life expectancy of patients undergoing bariatric procedures means many of these patients will succumb to other diseases. Altered GI anatomy after bariatric procedures could prove an obstacle in treatment. We present our management of one such occurrence. The patient, who had 5 years previously undergone a Roux-en-Y gastric bypass, presented after a massive subarachnoid hemorrhage which resulted in spastic tetraplegia. He was unable to consume food and was at risk of malnutrition. A decision was made to laparoscopically create a percutaneous gastrostomy (PEG) into the excluded stomach, allowing for the use of standard feeding formula and avoiding the need for parenteral nutrition and prolonged hospitalization due to metabolic complications. The growing number of patients following bariatric procedures directs the need for novelty treatment options suited to the altered anatomy and physiology of the patient post-bariatric surgery. Prompt evaluation of long-term complications after cardiovascular events in patients operated with bariatric surgical technics reduced nutritional complications, rated hospital stay, and improved quality of life. In those patients who, due to the localization of the brain defect, are expected to be unable to feed independently due to the consequences of the latter and have either long-term or lifelong feeding through feeding tubes, it is necessary to establish an enteral feeding pathway through which the patient can receive a standard nutritional formula. This prevents the patient from developing metabolic complications and related complications. At the same time, we enable inpatient accommodation without the risk of dietary complications associated with bariatric surgery.

Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass

Background: Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). Furthermore, in these patients, CBDS are difficult to extract due to the altered upper gastrointestinal anatomy following GBP. The aim of the present study was to assess outcome after various management methods applied in the counties of Stockholm and Uppsala, Sweden. Methods: Data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) and the Swedish Obesity Surgery Register (SoReg) were crossmatched to identify all patients who had undergone gallstone surgery after GBP, where CBDS were found at intraoperative cholangiography, in the Stockholm and Uppsala counties 2009-2013. A retrospective review of patient records was performed for all patients identified. Results: In all, 55 patients were identified. These were managed as follows: expectancy (N = 11); transgastric ERCP (N = 2); laparoscopic choledochotomy (N = 3); open choledochotomy (N = 5); transcystic stone extraction (N = 12); and other approach (N = 13). In nine cases, data on management could not be found. There were nine cases of minor postoperative complication. No retained stones were registered. The operation time was longer for transgastric ERCP (p = 0.002), and the postoperative stay was longer following open and laparoscopic choledochotomy (p < 0.001). There was no statistically significant difference between any of the methods regarding the incidence of postoperative complications (p = 0.098). Discussion: Further development of techniques for managing CBDS discovered in patients undergoing cholecystectomy after previous GBP are needed, as well as more comparative studies with greater statistical power.