Gastric Fistula After Sleeve Gastrectomy: Clinical Features and Treatment Options

Analysis of intra- and postoperative interventional endoscopic measures in 3000 bariatric surgical procedures over 15 years: a single center study

In addition to preoperative diagnostic gastroscopy, some bariatric surgery patients require one or more differentiated endoscopic interventions as part of postoperative complication management. The aim of this study is to analyze endoscopic interventions regarding indication, type of procedure, material used, and outcome. We prospectively collected and retrospectively analyzed data over a period of 15 years from 2006 to 2021 of all consecutive patients who underwent an interventional upper gastrointestinal endoscopy after bariatric surgery at our center. The primary study objective was the type and frequency of the treatment. Secondary study objectives included clinical outcomes and postinterventional complications. Of 3000 bariatric procedures, 145 (4.8%), among them 11.1% (n = 54) of 485 Roux-en-Y gastric bypasses, 7.1% (n = 20) of 282 redo operations, 5.7% (n = 20) of 351 revisional operations, 3.3% (n = 13) of 398 sleeve gastrectomies, and 1.9% (n = 26) of 1394 one-anastomosis gastric bypasses, received an interventional endoscopy for postoperative complication management. 79.3% (n = 115) were female, mean age was 42.4 (± 10.7) years, mean BMI was 43.5 (± 9.8) kg/m2. Complication after interventional endoscopy happened in 1.6%, revisional surgery was necessary in 0.5% (n = 3). Causes for endoscopic intervention were stenosis (52.4%), leakage/fistula (35.9%), intraluminal bleeding (13.1%), dumping syndrome (9.0%), and gallstones (1.4%). The performed interventions were balloon dilation (48.3%), stent therapy (33.1%), metallic clipping (12.4%), injection therapy (0.09%), bougienage (0.07%), vacuum therapy (0.06%), and pigtail therapy (0.04%). Endoscopic intervention is an effective and safe way of treating adverse events after bariatric surgery. Stenosis and leakage were the most frequent complications, with endoscopic balloon dilatation and stent therapy as the most frequent and successful treatment options. RYGB was the procedure with the most endoscopic interventional involvement. To better learn about outcomes of specific endoscopic techniques further studies preferably with larger multicenter samples are required.

Primary, revisional, and endoscopic bariatric surgery: a narrative review of abdominal emergency management for general surgeons

Minimally invasive approaches like endoscopic, laparoscopic, and robotic surgery have revolutionized bariatric and metabolic surgery (MBS). Despite the safety of MBS in specialized centers, acute complications requiring emergency treatment may occur and present challenges for general surgeons, especially in community hospitals. This is further complicated by the rising popularity of bariatric surgery tourism and the increasing diversity of bariatric surgical techniques. This paper provides an updated review of the management of acute abdominal complications after minimally invasive MBS, intending to guide general surgeons in managing these patients, especially in emergency settings where specialized bariatric care may not be readily available.

Laparoscopic Sleeve Gastrectomy Lacks Intrasurgeon and Intersurgeon Agreement in Technical Key Points That May Affect Gastroesophageal Reflux Disease After the Procedure

PURPOSE

Gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) may be related to surgical technique. The fact that there is a lack of technical standardization may explain large differences in GERD incidence. The aim of this study is to evaluate auto- and hetero-agreement for SG technical key points based on recorded videos.

METHODS

Ten experienced (minimum of 5 years performing bariatric surgery, minimum of 30 SG per year) bariatric surgeons (9 (90%) males) were selected. Participants were invited to send an unedited video with a typical laparoscopic SG (first round of the Delphi process). Videos were cropped into small clips comprising 11 key points of the technique. All anonymized clips (including their own) were returned to all surgeons. Individuals were asked to agree or not with the technique demonstrated (second round). The percentage of agreement was presented to the entire group that was asked for a second vote (third round).

RESULTS

Agreement was poor/fair for all points except hiatal repair that had a very good agreement in the second round. For the third round, there was a slight increase in agreement for distance esophagogastric junction/proximal stapling and gastric mobilization for stapling and a slight decrease in agreement for gastric tube final shape. Only 1 (10%) surgeon recognized that he evaluated his own video. Five (50%) surgeons disagreed with themselves on 1 or more points.

CONCLUSION

SG lacks intrasurgeon and intersurgeon agreement in technical key points that may justify significant differences in GERD incidence after the procedure.

Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry

BACKGROUND

Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting.

METHODS

To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks.

RESULTS

A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor.

CONCLUSIONS

Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.

Treatments for Staple Line Leakage after Laparoscopic Sleeve Gastrectomy

The number of laparoscopic sleeve gastrectomies (LSGs) performed in patients with obesity who are eligible for bariatric and metabolic surgery is currently much lower in Japan than in other countries. Considering the large number of potential patients with obesity and type 2 diabetes and the unique Japanese national health insurance system that guarantees fair healthcare delivery, there is room to increase the number of LSGs in Japan in the near future. However, strict health insurance regulations may limit access to mandatory devices needed to treat postoperative complications, such as staple line leakage, which can cause severe morbidity and even mortality. Therefore, understanding the pathogenesis and treatment options for this complication is crucial. This article examined the current situation in Japan and its impact on staple line leakage management, including the role of endoscopic treatment in reducing reoperation. The authors suggest increasing education and collaboration between healthcare professionals to optimize management and improve patient outcomes.

GASTRIC TWIST AFTER SLEEVE GASTRECTOMY: A PROPOSAL FOR ENDOSCOPIC CLASSIFICATION

ABSTRACT - BACKGROUND: The twisting of the gastric tube is one of the main causes of persistent reflux and food intolerance after sleeve gastrectomy (SG). To date, there is no classification for gastric twist after SG. OBJECTIVE: This study aimed to propose an endoscopic classification for this condition and outline the clinical profile of these patients with sleeve gastrectomy. METHODS: Patients in the postoperative period of SG presenting endoscopic findings of gastric twist were included. All patients underwent an esophagogastroduodenoscopy 12 months after SG. The classification proposed consists of three degrees: degree I: mild rotation of the staple line without relevant shrinkage of the gastric lumen; degree II: moderate rotation of the staple line, leading to a focal area of fixed narrowing that requires additional maneuvers for its transposition; and degree III: severe rotation of the staple line leading to stenosis, with increased difficulty for transposition or complete blockage. RESULTS: Out of 2,723 patients who underwent SG, 45 (1.6%) presented gastric twist. Most patients were female (85%), with mean age of 39±10.4 years. In all, 41 (91.1%) presented degree I, 3 (6.7%) presented degree II, and 1 (2.2%) had degree III. Most patients were asymptomatic (n=26). Vomiting was the most prevalent symptom (15.5%). Statistically significant correlation of twisting degrees was not observed for both the presence of symptoms and the degrees of esophagitis. CONCLUSION: Gastric twist after SG is rare, with generally mild and asymptomatic presentation. The endoscopic classification was not statistically related to clinical presentation but set the ground for further analysis.