Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.

Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery

Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease (GERD) or worsening of pre-existing GERD. The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation. However, there is currently no standardized approach for the assessment of GERD in these patients. In this review, we delineate the relationship between GERD and the most common bariatric surgeries: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with a focus on pathophysiology, objective assessment, and underlying anatomical and motility disturbances. We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB, determine the underlying cause, and guide the management and treatment.

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

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.

[Management of Endoscopic Complications after Bariatric Surgery: Focus on Current Endoscopic Therapy]

In bariatric surgery, complications are rare. Most of the complications can be managed by endoscopy. Rare complications impose a challenge in everyday clinical work. To optimally treat the complications and to minimise the harm to the patient it is important to implement complication management. This review gives an overview of relevant bariatric complications and endoscopic therapy strategies, focusing on published literature of the last five years. This manuscript could be a starting point for complication management in the clinic.

Endoscopic Vacuum Therapy (EVT) for the Treatment of Post-Bariatric Surgery Leaks and Fistulas: a Systematic Review and Meta-analysis

Bariatric surgery remains the most effective treatment for morbid obesity and its comorbidities. However, post-surgical leaks and fistulas can occur in about 1-5% of patients, with challenging treatment approaches. Endoscopic vacuum therapy (EVT) has emerged as a promising tool due to its satisfactory results and accessibility. In this first systematic review and meta-analysis on the subject, EVT revealed rates of 87.2% clinical success, 6% moderate adverse events, and 12.5% system dislodgements, requiring 6.47 EVT system exchanges every 4.39 days, with a dwell time of 25.67 days and a total length of hospitalization of 44.43 days. Although our results show that EVT is a safe and effective therapy for post-surgical leaks and fistulas, they should be interpreted with caution due to the paucity of available data.

Comparison of 5-Year Follow-up Outcomes Between Primary and Revision Roux-en-Y Gastric Bypasses After Open Vertical Banded Gastroplasty: an Inverse Propensity Score-Weighted Analysis

INTRODUCTION

Vertical banded gastroplasty (VBG) is associated with high weight regain; Roux-en-Y gastric bypass (RYGB) is used as a revision procedure in patients with VBG experiencing weight regain. This study compared the 5-year follow-up outcomes of primary (PRYGB) and revision RYGB after VBG (RRYGB).

METHODS

Patients who underwent PRYGB or RRYGB after VBG from 2008 to 2016 were enrolled. Data on weight regain, weight loss (WL), food tolerance (FT), early and late complications, and resolution or improvement in associated medical conditions were analyzed.

RESULTS

PRYGB and RRYGB groups had 558 and 156 patients, respectively, after exclusion of the lost to follow-up patients. PRYGB group showed significantly lower mean body mass index (over the entire follow-up period), early complications, reintervention rates for late complications, and overall reintervention rates than that of the RRYGB group. On the other hand, FT scores, odds of late complications, and improvements (in the fifth year) in associated medical conditions were comparable between the two groups.

CONCLUSION

RRYGB in patients with VBG who regained weight showed comparable safety and resolution of associated diseases to that of PRYGB over the 5-year follow-up period. The WL in the RRYGB group was acceptable despite being less than that of the PRYGB group. FT was better after RRYGB than that of PRYGB in the first year; however, both were comparable at the fifth year follow-up. Patients with VBG undergoing RYGB should receive attentive treatment and evaluation of associated factors.

Status of bariatric endoscopy–what does the surgeon need to know? A review

BACKGROUND

Obesity is a chronic and multifactorial disease with a variety of potential treatment options available. Currently, there are several multidisciplinary therapeutic options for its management, including conservative, endoscopic, and surgical treatment.

AIM

To clarify indications, technical aspects, and outcomes of bariatric endoscopy.

METHODS

Narrative review of current literature based on electronic databases including MEDLINE (PubMed), Cochrane Library, and SciELO.

RESULTS

Bariatric endoscopy is in constant development and comprises primary and revisional treatment options as well as management of surgical complications. Various devices act upon different mechanisms of action, which may be individualized to each patient. Despite favorable results for the endoscopic treatment of obesity, prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies. Regarding the management of bariatric surgery complications, endoscopic therapy may be considered the procedure of choice in a variety of situations. Still, as there is no standardized algorithm, local experience should be considered in decision-making.

CONCLUSION

The treatment of patients with obesity is complex, and a multidisciplinary approach is essential. Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications, and therefore, must be part of the armamentarium in the fight against this disease.

Nutritional Support and Duration of Drainage Recommendations for Endoscopic Internal Drainage: Review of the Literature and Initial Experience

INTRODUCTION

Anastomotic leaks following foregut surgery pose a difficult scenario for surgeons. While definitive surgical options are more invasive and may result in diversion requiring subsequent surgeries, endoscopic management of these leaks has been shown to work as an alternative platform for management. An evolving option is endoscopic internal drainage. We have reviewed our experience using endoscopic internal drainage and report our outcomes.

MATERIALS AND METHODS

An institution review board approved prospectively gathered database was used to identify all patients undergoing endoscopic internal drainage following esophageal and gastric leaks. Patient demographics, sentinel operation causing the leak, and outcomes of therapy were collected. The rate of healing and complications with the drainage catheter in place were the primary endpoints.

RESULTS

Sixteen patients were identified (5 male, 11 female) that underwent endoscopic internal drainage with a mean age of 48 and mean BMI of 30.8. Overall success rate was 69% (11/16), where 4 patients required a definitive surgery, and one healed with endoluminal vacuum therapy. Of the 4 failures, 1 patient required esophagojejunostomy, 2 patients required a fistulojejunostomy, and one required a partial gastrectomy. A total of 12 patients (75%) had a prior endoscopic procedure that was unsuccessful. The mean duration of drainage catheter in place was 48 days. While the catheter was in place, 4 patients were allowed minimal PO intake in conjunction with total parenteral nutrition or tube feeds. The rest of the patients were strict NPO with other means of nutrition. There were no complications with the drainage catheters and no deaths.

CONCLUSION

Leaks following esophagogastric surgery are difficult to manage; however, endoscopic internal drainage has been shown to be effective. Duration of the technique should be around 6 to 8 weeks with nutritional support guided by the comfort of the managing clinician.

Treatment of Persistent Large Gastrocutaneous Fistulas After Bariatric Surgery: Preliminary Experience with Endoscopic Kehr's T-Tube Placement

Purpose

Post-bariatric surgery gastrocutaneous fistula is a chronic leak with an incidence of 1.7 to 4.0% and no standardized management. A large gastrocutaneous fistula (LGCF) is not indicated for treatment with pigtail drains. We aimed to evaluate results of a novel treatment using endoscopic Kehr’s T-tube placement.

Methods

Only patients with a postoperative LGCF duration of > 10 days and a flow rate of > 50 cc by external drainage after revisional surgery for sepsis were included. Endoscopic placement of Kehr’s T-tube was performed. Patients had been reoperated with wash and drainage for severe sepsis after initial bariatric surgery in which no fistula had been discovered. Patients not reoperated, or with a fistula requiring intraoperative Kehr’s T-tube placement, or a pigtail drain were excluded. Primary outcomes were endoscopic characteristics and results (LGCF closure rate, Kehr T-tube retention time, etc.).

Results

The study group included 12 women, 2 men; body mass index 43.1 ± 4.5 kg/m². Interventions were SG (7), RYGB (2), OAGB (4), and SADI-S (1). Endoscopic assessment was carried out after a mean of 33.2 ± 44.3 days after the bariatric procedure. The mean fistula orifice diameter was 2.0 ± 0.9 cm. Kehr’s T-tube was positioned at a mean 51.5 ± 54.8 days after the bariatric procedure. T-tube tolerance was excellent. Mean additional days: hospitalization, 34.4 ± 27.0; T-tube retention, 86.4 ± 73.1; fistula healing, 139.9 ± 111.5, LGCF closure rate, 92.9%. Complications: 1 pulmonary embolism, 2 T-tube migrations,1 drain-path bleed, 1 skin abscess. No mortality.

Conclusions

Endoscopic Kehr’s T-tube placement was successful in closing persistent post-bariatric surgery LGCF in 92.9% of patients.

Graphical abstract

Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results.

METHODS

We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients' clinical characteristics, duration and type of stent, other stent complications, and mortality.

RESULTS

A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52-89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32-22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94-17.14%). The agreement between reviewers for the collected data gave a Cohen's κ value of 1.0. No deaths were caused directly by complications with the stent placement.

CONCLUSIONS

Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.

Therapeutic endoscopy for the treatment of post-bariatric surgery complications

Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Role of Endoscopic Internal Drainage in Treating Gastro-Bronchial and Gastro-Colic Fistula After Sleeve Gastrectomy

BACKGROUND

Gastro-bronchial and gastro-colic fistulas (GB-GC) represent a rare, but serious complication after laparoscopic sleeve gastrectomy (LSG). The aim of this study is to evaluate the efficacy of endoscopic first-line approach with endoscopic internal drainage (EID) by inserting double pigtail stents (DPS) METHODS: We retrospectively analyzed data from 40 consecutive patients referred at two tertiary centers for gastro-bronchial (N=30) and gastrocolic (N=10) fistulas following LSG. Nineteen patients previously experienced emergency surgical drainage. The mean interval between the index surgery and endoscopic fistula treatment was 265.6±521 days.

RESULTS

Healing of the fistulous tract was achieved in 19 patients (47.5%), with complete resolution at an average follow-up of 16 months. Mean time of treatment duration was 157.8±141 days with 5.0±2.9 endoscopic sessions. No major adverse events were registered.

CONCLUSIONS

Despite complete fistula healing was achieved in less than 50% of our population, EID for GB/GC fistula after LSG still represents the most conservative approach with low complications rate. Previous surgical drainage seems to be a positive prognostic factor for endoscopic healing. While the longer the interval between the index surgery and endoscopic treatment, the lower was the rate of treatment success.

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

PURPOSE

Gastric staple line leakage (GL) is a serious complication of laparoscopic sleeve gastrectomy (LSG), with a specific mortality ranging from 0.2 to 3.7%. The current treatment of choice is stent insertion. However, it is unclear whether the type of stent which is inserted affects treatment outcome. Therefore, we aimed not only to determine the effectiveness of stent treatment for GL but also to specifically clarify whether treatment outcome was dependent on the type of stent (small- (SS) or megastent (MS)) which was used.

PATIENTS AND METHODS

A single-centre retrospective study of 23 consecutive patients was conducted to compare the outcomes of SS (n = 12) and MS (n = 11) for the treatment of GL following LSG. The primary outcome measure was the success rate of stenting, defined as complete healing of the GL without changing the treatment strategy. Treatment change or death were both coded as failure.

RESULTS

The success rate of MS was 91% (10/11) compared to only 50% (6/12) for SS (p = 0.006). An average of 2.3 ± 0.5 and 6.8 ± 3.7 endoscopies were required to achieve healing in the MS and SS groups respectively (p < 0.001). The average time to resumption of oral nutrition was shorter in the MS group (1.4 ± 1.1 days vs. 23.1 ± 33.1 days, p = 0.003).

CONCLUSIONS

Stent therapy is only effective and safe for the treatment of GL after LSG if a MS is used. Treatment with a MS may not only increase treatment success rates but may also facilitate earlier resumption of oral nutrition and shorten the duration of hospitalization.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Management of Leaks Following Laparoscopic Sleeve Gastrectomy Using Specifically Designed Large Covered Metal Stents

BACKGROUND

Leaks are the major complication associated with laparoscopic sleeve gastrectomy.

OBJECTIVE

The study aimed to assess the efficacy and safety of specifically designed large covered metal stents for the management of post-laparoscopic sleeve gastrectomy leaks.

METHODS

Prospectively collected databases from three Italian Endoscopy Units were reviewed. The primary outcome of the study was to evaluate the clinical success of stents placement, defined as complete resolution of clinical and laboratory signs of sepsis with radiological evidence of leak closure. Secondary outcomes were stent-related adverse events and mortality.

RESULTS

Twenty-one patients (67% females, mean age 45 years) were included in the study and a total of 26 stents were placed. Technical success of stent placement was achieved in all cases (100%). Clinical success was observed in 85.5% of patients. Stent-related adverse events occurred in 9 patients (43%), with stent migration as the most frequent complication (33%). Adverse events were more frequently observed in patients who had undergone bariatric surgery prior to laparoscopic sleeve gastrectomy compared to patients without previous surgery (83% et al. 27%, p=0.018).

CONCLUSION

The placement of specifically designed covered metal stents appears to be an effective and safe therapeutic approach for post-laparoscopic sleeve gastrectomy leaks. Stent migration can be a frequent complication.

Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks

BACKGROUND AND AIMS

Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence.

METHODS

This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and 2019.

RESULTS

Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%.

CONCLUSIONS

Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.

Endoscopic Negative Pressure Therapy (ENPT) Is Superior to Stent Therapy for Staple Line Leak After Sleeve Gastrectomy: a Single-Center Cohort Study

PURPOSE

Staple line leak (SLL) is a serious complication after sleeve gastrectomy (SG). Common endoscopic treatment options include self-expandable metallic stent (SEMS), endoscopic internal drainage (EID), and endoscopic closure. The endoscopic negative pressure therapy (ENPT) is a promising treatment option combining temporary sealing of the defect with drainage of the inflammatory bed. In this study, we compare the outcome of ENPT and SEMS for the treatment of SLL following SG.

MATERIALS AND METHODS

A retrospective cohort of 27 patients (21 females) treated at a single center for SLL after SG was included. ENPT was primary therapy for 14 patients and compared with 13 patients treated primarily using SEMS.

RESULTS

ENPT was associated with a significant reduction of hospital stay (19 ± 15.1 vs. 56.69 ± 47.21 days, p = 0.027), reduced duration of endoscopic treatment (9.8 ± 8.6 vs. 44.92 ± 60.98 days, p = 0.009), and shorter transabdominal drain dwell time (15 (5-96) vs. 45 (12-162) days, p = 0.014) when compared to SEMS. Whereas endoscopic management was successful in 12/14 (85.7%) of patients from the ENPT group, SEMS was successful in only 5/13 (38.5%) of patients (p = 0.015). Furthermore, ENPT was associated with a significant reduction of endoscopic adverse events compared with SEMS (14.3% vs. 76.92% p = 0.001).

CONCLUSION

Compared with SEMS, ENPT is effective and safe in treating SLL after SG providing higher success rates, shorter treatment duration, and lower adverse events rates.

Endoscopic Management of Staple Line Leak after Bariatric Surgery: Surgeon's Perspective

Laparoscopic sleeve gastrectomy (LSG) has become a standalone primary procedure as a bariatric metabolic surgery since the early 2000s. The overall complication rate of LSG is reported to range from 2% to 15%. Staple line leakage (SLL) remains a major adverse event and occurs in approximately 1–6% of patients. Choosing the optimal treatment modality is a complex process. Clinicians must understand that nutritional support and drainage of fluid collection are essential for initial management. Conservative endoscopic management and sufficient drainage can resolve approximately 70% of SLLs. Endoscopic management of bariatric complications has been rapidly evolving in recent years and can be considered in all patients who are hemodynamically stable. We will review the available endoscopic management techniques, including stent placement (self-expanding stents and bariatric-specific stents), clipping, tissue sealant application, and internal drainage (double-pigtail stents [DPS] placement, endoscopic vacuum therapy, and septotomy). Stent placement remains the mainstream treatment for SLLs. However, healing with stents requires multiple sessions/stents and a long course of recovery. Endoscopic internal drainage is gaining popularity and has the potential to be a superior method. The importance of early intervention and combined endoscopic methods should be recognized.

Outcome and Adverse Events of Endoscopic Bariatric Stents for Management of Leakage after Bariatric Surgery

INTRODUCTION

Bariatric leakage (BL) is a serious complication with a variety in available treatment options. Endoscopic stenting is preferred because of its minimally invasive nature in morbidly obese patients. Various modifications have been applied to stents since its use in palliation of malignant strictures. Few studies have exclusively evaluated the efficacy of bariatric stents in management BL.

METHODS

A retrospective cohort study of patients with BL managed by bariatric stents in the period between July 2014 and January 2019. The primary outcome was the clinical success in healing of leakage and secondary outcomes included adverse events (AEs), hospital stay and procedure-related mortality.

RESULTS

Forty-five patients were included in this study. Clinical success occurred in 33 patients (73.3%). There was no stent-related mortality. The most frequent stent-related complications were reflux (62.2%), intolerance (55.6%), and migration (17.8%). Severe AEs occurred in 9 patients (20%). The overall complications rate was higher in diabetic patients (P = 0.048). Intolerance was significantly associated with shorter interval to management (P = 0.02). Stent migration was higher in male patients (P = 0.019) and higher BMI (P = 0.024).

CONCLUSION

Endoscopic stenting is a double-edged weapon that must be handled cautiously. It is a highly effective therapy, and early intervention is the main determinant of its efficacy. But it is not a treatment without complications (80%). The variant and high prevalence of complications mandates a strict follow-up throughout the stenting duration.

Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients

BACKGROUND

Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases.

OBJECTIVES

To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG.

SETTING

Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center.

METHODS

EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)-guided deployment of DPS or lumen apposing metal stents.

RESULTS

A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818).

CONCLUSION

Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy: Low Efficacy of the Over-the-Scope Clip

PURPOSE

The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC.

RESULTS

Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35 years (range 18-62), and mean body mass index was 44 kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18 days (range 2-118), and 6 days (range 1-120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43 days of clip deployment (range 5-87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2).

CONCLUSIONS

OTSC carries a low success rate for controlling staple line leaks following LSG.

Percutaneous embolization for a subacute gastric fistula following laparoscopic sleeve gastrectomy: a case report and literature review

Background

The management for subacute or chronic fistula after bariatric surgery is very complicated and with no standard protocol yet. It is also an Achilles’ heel of all bariatric surgery. The aim of this case report is to describe our experience in managing this complication by percutaneous embolization, a less commonly used method.

Case presentation

A 23-year-old woman with a body mass index of 35.7 kg/m² presented with delayed gastric leak 7 days after laparoscopic sleeve gastrectomy (LSG) for weight reduction. Persistent leak was still noted under the status of nil per os, nasogastric decompression, and parenteral nutrition for 1 month; therefore, endoscopic glue injection was performed. The fistula tract did not seal off, and the size of pseudocavity enlarged after gas inflation during endoscopic intervention. Subsequently, we successfully managed this subacute gastric fistula via percutaneous fistula tract embolization (PFTE) with removal of the external drain 2 months after LSG.

Conclusions

PFTE can serve as one of the non-invasive methods to treat subacute gastric fistula after LSG. The usage of fluoroscopy-visible glue for embolization can seal the fistula tract precisely and avoid the negative impact from gas inflation during endoscopic intervention.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

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

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

Wernicke's encephalopathy in a patient with late-onset enterocolic fistula after bariatric surgery

Wernicke´s encephalopathy (WE) is an acute neurologic disorder secondary to thiamine deficiency. We report the case of a patient with history of bariatric surgery who develops a late-onset enterocolic fistula, with alcohol consumption associated.

Endoscopic Tunneled Stricturotomy with Full-Thickness Dissection in the Management of a Sleeve Gastrectomy Stenosis

INTRODUCTION

Laparoscopic sleeve gastrectomy is becoming the most commonly performed bariatric surgery. Despite clinical efficacy, adverse events have gradually increase due to its rapid adoption. Sleeve stenosis is the second most common adverse event, occurring in 0.7 to 4% of patients undergoing laparoscopic sleeve gastrectomy (LSG). Endoscopic management with pneumatic balloon dilation (PBD) or stent placement is commonly performed, with a success rate of up to 88%. Recently, Moura et al. (VideoGIE 4(2):68-71, 2018) described a new technique, named as endoscopic tunneled stricturotomy. In this video, we demonstrated the evolution of this technique including full-thickness dissection with staple line disruption.

METHODS

A 28-year-old woman with a BMI of 35.3 kg/m² who underwent LSG, presented with dysphagia to solid food. An upper GI series showed a stenosis at the level of the incisura angularis. The patient was then referred for endoscopic evaluation.

RESULTS

She underwent three endoscopic PBD in an attempt to treat the stenosis. Unfortunately, her symptoms did not improve. After failed PBD treatment, an endoscopic tunneled stricturotomy with full-thickness dissection was performed. The procedure is performed in 6 steps: (1) identification of the stenosis, (2) submucosal injection 3-5 cm before the stenosis, (3) incision, (4) submucosal tunneling, (5) stricturotomy with full-thickness dissection, and (6) mucosal closure. During follow-up, the patient maintained a 1200-cal diet, without recurrence of symptoms.

CONCLUSION

Endoscopic tunneled stricturotomy with full-thickness dissection is feasible and appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure may be an option after conventional treatment failure or may be considered as a primary alternative.

Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis

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.

Role of Cardiac Septal Occluders in the Treatment of Gastrointestinal Fistulas: A Systematic Review

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.

Endoscopic management of post-surgical GI wall defects with the overstitch endosuturing system: a single-center experience

BACKGROUND AND AIMS

Post-GI surgical wall defects are frequent and life-threatening complications, with limited literature regarding current treatment. This case series aims to assess the safety, feasibility, and outcomes of endoluminal therapy with the overstitch endoscopic suturing system (Apollo Endosurgery Inc, Austin).

MATERIALS AND METHODS

All patients who underwent endoscopic suturing for post-surgical wall defect management at IRCCS-ISMETT Palermo from October 2017 until January 2019 were retrospectively enrolled. Stratification therapy was applied according to the clinical scenario, time from surgery to endoscopic intervention, and structural condition of the wall defect layers (tissue status and suture feasibility). The therapeutic endoscopic strategy was divided into three groups (A: pure endoscopic direct suture; B: combined therapy with endoscopic direct suture + FC-SEMS placement + anchoring; C: FC-SEMS placement + anchoring). Success was considered the resolution of symptoms and the presence of a regular intestinal transit after a period of 4-6 weeks.

RESULTS

Twenty (20) patients (male/female 7/13; mean age 54 ± 13.43 years) were included in the study (group A: 9 patients, group B: 7 patients, group C: 4 patients). The types of operative procedures were bariatric (9/20), post-tracheostomy (3/20), post-operative GI surgery (8/20). The post-surgical defects were predominantly intermediate and chronic (24-72 h: 1/20; 3-30 days: 13/20; > 30 days: 6/20). The overall clinical success was 80% (17/20 patients), with a success of 94% (16/17 patients) when excluding the three cases of tracheo-esophageal fistula. No evidence of migration was detected. The only complication was short stenosis of the distal esophagus, present in 4 patients (19%) and successfully treated with a novel lumen-apposing metal stent.

CONCLUSIONS

In our experience, considering the absence of clear guidelines, the endoluminal approach with the overstich endoscopic suturing system is a valid alternative to conventional therapy, offering mini-invasiveness, and presenting promising opportunities in terms of technical feasibility and clinical efficacy.

Fistula Recurrence: A Clinical Reality after Successful Endoscopic Closure of Laparoscopic Sleeve Gastrectomy Fistulas

Background and Aims

Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas.

Methods

This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence.

Results

The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4-145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1-10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15-72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50-205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence.

Conclusions

A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically.

Key Messages

Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically.

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

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

Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects

A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.

Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas

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.

Efficacy of Endoscopic Treatment of Post-Sleeve Gastrectomy Fistulas According to the Radiological Type

BACKGROUND AND AIMS

The originality of this retrospective study relies on the evaluation of the effectiveness of the endoscopic internal drainage (EID) according to the type of fistula.

METHODS

The type of fistula was classified initially according to a CT scan with oral opacification: fistula without a communicating abscess (type I), fistula with a communicating abscess (type II), and fistula with an abscessed sub- and sus-diaphragmatic communicating collection (type III). Treatment algorithm consisted of the insertion of a nasojejunal feeding tube (NJFT) for type I fistulas and the placement of a NJFT with EID with or without surgical drainage for types II and III.

RESULTS

Forty-nine patients were included. The clinical success rate with fistula healing was 100% in group I, 96% in group II, and 12% for group III (p = 0.001). Mean time for diagnosis of the fistula was significantly higher in type III (p = 0.04). The mean estimated size of the defect was higher in type II, 11.2 mm and III, 10 mm versus type I, 2.8 mm (p = 0.001). The average number of scheduled endoscopic sessions were 2, 2.7, and 5.2 for types I, II, and III, respectively (p = 0.001). The number of unscheduled reinterventions was also significantly higher in type III (p = 0.03). The NJFT was left in place for a significantly longer duration in type III (136 days) compared to types I (3, 13) and II (49) p = 0.001.

CONCLUSION

This study shows that proper characterization of the type of fistula before the endoscopic treatment of post-sleeve fistulas improves the efficacy of the endoscopic treatment.