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

Endoscopic therapies for bariatric surgery complications

PURPOSE OF REVIEW

The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications.

RECENT FINDINGS

The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB.

SUMMARY

Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.

Prevention, detection and management of adverse events of third-space endoscopy

Third space endoscopy (TSE) or sub-mucosal endoscopy using a mucosal flap valve (SEMF) enables the endoscopist to operate in the deeper layers of the gastrointestinal tract or gain access to the mediastinal/peritoneal cavity for natural orifice transoral endoscopic surgery (NOTES). TSE procedures are essentially endoscopic surgical procedures with a variable learning curve. Adverse events (AEs) during TSE are specific and follow a certain pattern across the spectrum of TSE procedures. These can be broadly categorized according to either type of AE, time of presentation relative to the procedure or according to degree of severity. Three major categories of AEs encountered during TSE include insufflation related AEs, mucosal injuries (MIs) and bleeding. Other relevant AEs include infectious complications, aspiration pneumonia, post-procedural chest/abdominal pain, atelectasis, cardiac arrhythmias, pleural effusion and pulmonary embolism. Reported incidence of AEs during TSE procedures varies according to the type and complexity of procedure. Acquaintance regarding potential risk factors, technical tips and precautions, alarm signs for early recognition, assessment of degree of severity, morphological characterization of AEs and finally, expeditious selection of appropriate management strategy are crucial and imperative for successful clinical outcomes. The current review discusses the current evidence and practical guidelines for prevention, early detection and management of TSE-related AEs.

Endoscopic management of complications after sleeve gastrectomy: a narrative review

Sleeve gastrectomy (SG) has become the most widely performed bariatric procedure globally due to its technical simplicity and proven efficacy. However, complications following SG, including bleeding, leakage, fistulas, stenosis, gastroesophageal reflux disease (GERD), and hiatal hernia (HH), remain a significant concern. Endoscopic interventions have emerged as valuable minimally invasive alternatives to traditional surgical approaches for managing these complications. This review aims to provide a comprehensive overview of the endoscopic management strategies available for addressing the various complications encountered after SG, emphasizing their critical role in optimizing patient outcomes.

[Bariatric endoscopy-Possibilities and value in obesity medicine and surgery-A separate special field]

Endoscopy has become established as an important component in all preoperative, intraoperative and postoperative areas of bariatric surgery. As guidelines are not yet available, relevant studies and international position papers have been collected in this article. Preoperatively, endoscopy should be performed before sleeve gastrectomy (SG, detection of reflux status) and before bypass procedures (status survey of the postoperatively no longer accessible distal stomach). Routine endoscopic monitoring should be performed 2-3 years after SG and a OAGB (one anastomosis gastric bypass) for recording of the gastroesophageal reflex disease (GERD) status. In the first line complication management of hemorrhage and leakages, endoscopic procedures have prevailed over surgical ones due to more causal therapeutic approaches (except cases of general peritonitis where lavage and drainages are needed). In the treatment of late complications such as dumping, anastomosis dilatation and stenosis, bariatric endoscopy provides versatile, organ-preserving solutions and continues to demonstrate a high degree of innovation. In these postoperative fields of application, especially in the treatment of late complications, specific knowledge of bariatric anatomy and physiology as well as surgical treatment options are required in addition to endoscopic expertise. The special field of bariatric endoscopy has developed and will have an own importance closely linked to the bariatric surgery.

[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 Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

Gastric Per-Oral Endoscopic Myotomy for Treatment of Chronic Proximal Staple Line Leak Precipitated by Downstream Stenosis

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric surgery. Although considered a safe procedure, adverse events such as staple line leak in the context of sleeve stenosis can result in significant patient morbidity and health economic burden. Correction of the downstream stenosis is mandatory for closure of the staple line leak. Conventional endoscopic therapies offer high initial success rates, though ultimately a significant proportion proceed to revision surgery. Gastric per-oral endoscopic myotomy (G-POEM) is a novel, minimally invasive procedure which allows for a full-thickness myotomy of the stenosed segment, potentially conferring similar anatomical correction to surgical seromyotomy. We present a case of recalcitrant chronic proximal staple line leak in the context of a downstream gastric stenosis managed by G-POEM.

Endoscopic Management of Post-Laparoscopic Sleeve Gastrectomy Leakage and Stenosis Using Fully Covered Stent

Background

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed surgery to treat morbid obesity. Post-LSG leak and stenosis are serious complications that can be associated with significant morbidity and mortality.

Objective

The objective was to report the efficacy and safety profile of using specifically designed fully covered self-expandable metallic stent for the treatment of post-LSG complications.

Methods

This retrospective study included adult patients who underwent placement of a fully covered esophagogastric, self-expandable metallic stent for post-LSG leak or stenosis. The procedure was carried out at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between September 2017 and May 2019. Data regarding demographics, indication for stenting, size of the stent, procedural success and poststenting adverse events were collected.

Results

A total of 14 patients met the inclusion criteria, with indication for endoscopic stenting being post-LSG leak in 11 patients and stenosis in 3 patients. The technical success rate of self-expandable metallic stent placement was 100%, and the clinical success was 85.7% (12 of 14 patients). Nausea (71.4%) and vomiting (85.7%) were the most frequent mild adverse events reported. Stent-induced esophageal stricture was the only major adverse event reported in two patients.

Conclusion

Placement of specifically designed self-expandable metallic stent for the treatment of post-LSG leak and stenosis is an effective and safe approach. Further studies with larger cohorts are needed to assess the optimal duration needed to treat such complications.

Gastric Stenosis After Sleeve Gastrectomy: an Algorithm for Management

BACKGROUND

Gastric stenosis (GS) is a well-recognized complication after sleeve gastrectomy (SG) with a negative impact on patients' nutritional status and quality of life. There is no consensus on a validated, comprehensive management algorithm for GS. This study evaluates treatment modalities and proposes a management algorithm for obstructive gastric symptoms (OGSs) after SG.

METHODS

This is a retrospective cohort study of patients with GS after SG between January 2013 and January 2019. Patients with concomitant GS and staple-line leak were excluded. The primary outcome was the clinical response to treatment.

RESULTS

Forty-nine patients presented with OGSs. One patient underwent urgent surgical treatment for acute migration of cardia. Of 42 patients who had evident GS, pneumatic balloon dilatation (PBD) achieved clinical success in 28 (66.7%) patients. Six patients were diagnosed with indolent GS, and four of them improved after empirical PBD. The mean interval from index surgery to PBD was 5.3 (± 4.2) months. Longer duration of PBD session was associated with better clinical outcomes (5.8 ± 3.7 vs. 3.2 ± 1.7 min) (P = 0.017). After failed PBD, endoscopic stenting (n = 2) and revisional surgery (n = 7) were performed with clinical success in all patients.

CONCLUSION

PBD using achalasia balloon is the mainstay of treatment with good clinical outcomes. The utility of endoscopic stenting for GS should be different from its use for leakage in aspects of dwelling time and required endoscopic expertise. RYGB is the gold standard revisional procedure due to the high success rate and technical familiarity. Controversial aspects of management require future prospective comparative studies.