Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents

Managing Leaks and Fistulas After Laparoscopic Sleeve Gastrectomy: Challenges and Solutions

Postoperative leaks after sleeve gastrectomy are a troublesome complication that occur in 0.7-5.3% of cases depending on the referenced source. These complications cause significant morbidity for patients requiring prolonged hospitalizations, nutritional support, intravenous antibiotics, and at times additional operations and procedures that risk further downstream complications. The patient presentation varies from relatively benign with minimal or no symptomatology, to the acutely ill with life-threatening sepsis. The management of gastric leak is dependent on a multitude of factors, including the initial presentation as well the surgeon's experience and preference. Here, we will summarize the current literature and discuss the different options that exist for the management of gastric leaks after sleeve gastrectomy including laparoscopic lavage, endoscopic stenting, endoscopic pigtail catheters, endoscopic vacuum therapy, and salvage surgical operations such as fistula jejunostomy and total gastrectomy. The aim is to provide a source for surgeons to reference when they encounter this disease pathology and to shed light on a daunting challenge for the modern bariatric surgeon.

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.

New Endoscopic Devices and Techniques for the Management of Post-Sleeve Gastrectomy Fistula and Gastric Band Migration

Post-sleeve gastrectomy fistulas are a rare but possibly severe life-threatening complication. Besides early reoperation and drainage, endoscopy is the main treatment option. According to the clinical setting, endoscopic treatment options comprise stent or clip placement. New endoscopic therapies have recently gained attention, including endoscopic vacuum therapy, VacStent therapy, endoscopic internal drainage with pigtail stents, endoscopic suturing and stem cell injection. In this narrative review, we shed light on recent literature, developments, indications and contraindications of these treatments. Intragastric gastric band migration is a rare complication after gastric band positioning. Reoperation can sometimes be difficult, especially when a gastric band has already migrated far into the stomach. Endoscopic retrieval can be a valid, non-invasive therapeutic solution. We reviewed the current literature on this matter.

Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks.

METHODS

A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed.

RESULTS

The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43 years and a median follow-up of 24 months. The mean preoperative body mass index was 45.1 kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6 weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45 days after the index surgery.

CONCLUSIONS

Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6 weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

Closure of Gastrocutaneous Fistula Following Bariatric Surgery: a Systematic Review

Gastrocutaneous fistula (GCF) is a devastating complication that can arise after bariatric and metabolic surgery (BMS). This systematic review examines the success rate of closure techniques of GCF. A systematic search was conducted across MEDLINE, Embase and Cochrane databases to identify studies which reported on closure techniques of GCF after BMS in adults. Thirty-three studies (n = 108 patients) were included. Seventeen different techniques were used to close GCF across all studies. The most popular were stents (n = 17), tissue sealants (n = 12) and over-the-scope clips (n = 11). Twenty-one studies used multiple techniques to attempt closure, including endoscopic vacuum therapy and revisional surgery. This systematic review demonstrates current practice focusing on endoscopic methods such as stents and over-the-scope clips, with relative success in closing GCF.

Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience

BACKGROUND

Gastric (anastomotic or staple-line) leaks after bariatric surgery are rare but potentially life-threatening complications. Endoscopic vacuum therapy (EVT) has evolved as the most promising treatment strategy for leaks associated with upper gastrointestinal surgery.

OBJECTIVE

The aim of this study was to evaluate the efficiency of our gastric leak management protocol in all bariatric patients over a 10-year period. Special emphasis was placed on EVT treatment and its outcome as a primary treatment or as a secondary treatment when other approaches failed.

SETTING

This study was performed at a tertiary clinic and certified center of reference for bariatric surgery.

METHODS

In this retrospective single-center cohort study, clinical outcomes of all consecutive patients after bariatric surgery from 2012 to 2021 are reported, with special emphasis placed on gastric leak treatment. The primary endpoint was successful leak closure. Secondary endpoints were overall complications (Clavien-Dindo classification) and length of stay.

RESULTS

A total of 1046 patients underwent primary or revisional bariatric surgery, of whom 10 (1.0%) developed a postoperative gastric leak. Additionally, 7 patients were transferred for leak management after external bariatric surgery. Of these, 9 patients underwent primary and 8 patients underwent secondary EVT after futile surgical or endoscopic leak management. The efficacy of EVT was 100%, and there were no deaths. Complications did not differ between primary EVT and secondary treatment of leaks. Length of treatment was 17 days for primary EVT versus 61 days for secondary EVT (P = .015).

CONCLUSIONS

EVT for gastric leaks after bariatric surgery led to rapid source control with a 100% success rate both as primary and secondary treatment. Early detection and primary EVT shortened treatment time and length of stay. This study underlines the potential of EVT as a first-line treatment strategy for gastric leaks 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.

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.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.

Endoscopic internal drainage using transmural double-pigtail stents in leaks following upper gastrointestinal tract surgery

INTRODUCTION

different endoscopic procedures have been proposed for the management of surgical leaks. Endoscopic internal drainage using trans-fistulary double-pigtail plastic stents has emerged as an alternative strategy, especially in fistulae presenting after laparoscopic gastric sleeve.

METHODS

a retrospective case series was performed at a single tertiary care center including all upper gastrointestinal post-surgical leaks primarily managed with endoscopic trans-fistulary insertion of double-pigtail plastic stents. Clinical success was defined as the absence of extravasation of oral radiographic contrast and radiological resolution of the collection with adequate oral intake Results: nine patients were included, six (66.6 %) females with a median age of 52.6 years (IQR 47-60). Five cases presented after laparoscopic gastric sleeve, two cases after distal esophagectomies, one after a Roux-en-Y gastric bypass and another one after a pancreaticoduodenectomy. Fistulae measured < 10 mm in five patients (55.6 %) and 10-20 mm in four patients (44.4 %). Six were early leaks. Technical and clinical success was achieved in nine (100 %) and seven (77.8 %) cases, respectively. Seven (77.8 %) patients required ≤ 3 endoscopic procedures. The median hospital stay after the first endoscopic procedure was 12 days (IQR 6.5-17.5 days), while the overall median time until leak healing was 118.5 days (IQR 84.5-170). One patient with a post-esophagectomy intrathoracic leak developed an esophageal-tracheal fistula 37 days after stent deployment.

CONCLUSIONS

our results support the use of endoscopic internal drainage in postsurgical abdominal leaks, regardless of the type of surgery. Although only two patients with intrathoracic dehiscence were included.

Leak After Sleeve Gastrectomy: Updated Algorithm of Treatment

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is currently the most common procedure performed worldwide, and still the leak is considered the main limitation. After an initial enthusiasm for stents, the endoscopic treatment evolved including in the current management the septotomy with balloon dilatation and pigtails insertions. The aim of this study was to evaluate the updated algorithm of endoscopic treatment of leak following LSG including septotomy and balloon dilatation.

METHODS

All consecutive patients treated by endoscopy between January 2018 and March 2020 for leak following LSG were included in the current study. After recording the demographic and the leak history, we have analyzed the number of endoscopic sessions, the duration of treatment, and the healing rate of endoscopic treatment for 3 groups: A, small orifice (< 10 mm); B, large orifice (> 10 mm) and acute leak; and group C with large orifice and late leak.

RESULTS

A total of 53 patients received endoscopic treatment for leak following LSG. The leaks achieved complete healing after average duration of 3.2 months (range 1-7 months), 2.3 months for group A, 4.2 months for group B, and 3.7 months for group C. The average number of endoscopic procedures was 2.8 (range 2-6) and was required for general population: for group A, 2.3 sessions; in group B, 3.4 sessions; and in group C, 2.7 sessions. Two out of 53 patients (3.8%) required additional treatment outside of the current algorithm, one in group A and another in group B. One patient was transferred for pulmonary abscess, and for another patient, the leak was considered chronic after a total of 14 months, and a laparoscopic fistula-jejunostomy was performed with favorable outcomes.

CONCLUSIONS

Although there is still no consensus for endoscopic management of leaks after LSG, the benefits of pigtails and the septotomy are undeniable, and it should be included in the armamentarium of any bariatric endoscopic service.

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.

To oversew or not to oversew in robotic sleeve gastrectomy: a case against oversewing the staple line

BACKGROUND

The benefits of oversewing the staple lines during laparoscopic sleeve gastrectomy have been controversial. No study examined the benefit of oversewing the staple lines in robotic sleeve gastrectomy (RSG). This retrospective study aims to examine the difference in immediate postoperative complications, readmissions, reoperations, and emergency room visits between RSG patients with and without oversewn staple lines at a single, large-volume, bariatric center.

METHODS

A retrospective chart review was conducted on 623 patients who underwent RSG between November 1, 2017, and November 1, 2019. Of these, 316 had their staple line oversewn between November 1, 2017, and November 12, 2018, and 307 did not have their staple line oversewn between November 13, 2018, and November 1, 2019.

RESULTS

A total of 623 patients underwent RSG, of which 50.7% (n = 316) had their staple line oversewn. The mean length of hospital stay was similar between the two groups. However, the mean operative time was significantly longer in the "oversew" group than "no oversew" group by 7.4 minutes (p < 0.001). Readmission, reoperation, and intervention rates during the 30-day postoperative period were similar between the two groups. However, the percentage of patients requiring outpatient emergency room visits during the 30 days after RSG was significantly higher in the "oversew" group than that of the "no oversew" group.

CONCLUSIONS

No significant difference in major complications was found between RSG patients with and without oversewn staple lines. Oversewing of the staple line may be associated with increased emergency room visits.

Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis

OBJECTIVE

Recently, there has been a burgeoning interest in the utilization of customized bariatric stents (CBS) for management of sleeve gastrectomy leak (SGL). We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these new stents and to compare them with the conventional esophageal stents (CES).

METHODS

A systematic literature search of the PubMed, Cochrane Library, Scopus, Web of Science and Google Scholar databases was conducted through May 1, 2020. Primary outcomes were technical and clinical success and post-procedure adverse events of CBS and CES. Secondary outcomes were number of stents and endoscopic sessions per patient, and time to leak closure. A proportion meta-analysis was performed on outcomes using a random-effects model, and the weighted pooled rates (WPRs) or mean difference with 95% confidence interval (CI) were calculated.

RESULTS

The WPR with 95% CI of technical success, clinical success, and stent migration for CBS were 99% (93-100%) I2 = 34%, 82% (69-93%) I2 = 58%, and 32% (17-49%), I2 = 69%, respectively. For CES, the WPR (95% CI) for technical success, clinical success, and stent migration were 100% (97-100%) I2 = 19%, 93% (85-98%) I2 = 30%, and 15% (7-25%), I2 = 41%, respectively. Adverse events other than migration were very low with both types of stents. On proportionate difference, CBS had lower clinical success (11%) and higher migration rate (17%) in comparison to CES. In successfully treated patients, CBS was associated with lower mean number of stents and endoscopic sessions, and shorter time to leak closure compared to CES. The overall quality of evidence was very low.

CONCLUSIONS

In treatment of SGL, there is very low level evidence that CES are superior to CBS in terms of clinical success and migration rate, though may require more stent insertions and endoscopic procedures. The evidence however remains very uncertain. Perhaps relevant to some types of stents, CBS are promising; however design modification is strongly recommended to improve outcomes.

Gastrointestinal fistula endoscopic closure techniques

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents

BACKGROUND

the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option.

AIMS

the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks.

METHODS

a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018.

RESULTS

twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach.

CONCLUSIONS

endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

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.

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.

A case of intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak

•

The most frequent and severe complication after laparoscopic sleeve gastrectomy is gastric leak.

•

The endoscopic placement of a double-pigtail drain across the leak has been proven to be effective and minimally invasive.

•

Drain’s migration into the abdominal cavity is not common and its intrasplenic displacement is even more rare.

•

Pigtail drain migration involving the spleen may expose the patient to the risk of parenchymal abscess or haemorrhage.

Introduction

The most frequent and severe complication after laparoscopic sleeve gastrectomy is gastric leak. Nowadays, there is no specific standard recommendation for its management, but the endoscopic placement of a double-pigtail drain across the leak has been proven to be effective and minimally invasive. Stent displacement into the abdominal cavity is not common and intrasplenic migration is even more rare.

Case presentation

We report a case of a 49-year-old woman with intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak.

Discussion

Pigtail drain migration involving the spleen is rare but may potentially expose the patient to the risk of parenchymal abscess or haemorrhage. Often the clinic does not indicate early this complication.

Conclusion

We underline the need for a close radiologic follow-up, regardless of clinical conditions, in all patients treated with double-pigtail drain and its early removal in case of migration.

[Endoscopic management of complications after laparoscopic sleeve gastrectomy]

Laparoscopic sleeve gastrectomy (SG) is currently the most commonly performed standalone bariatric procedure worldwide. Gastric staple line leakage is the feared immanent complication of the operation, which is difficult to treat and often persists. This article presents the endoscopic treatment options for complications after laparoscopic SG, particularly the treatment of gastric staple line leakage. Most important for a successful treatment is the understanding of the underlying pathophysiological causes, the exact surgical comprehension of the procedure and advanced endoscopic skills. The choice of endoscopic intervention depends on the available strategies as well as on the skills of the executing endoscopist. Currently, internal drainage seems to be the most expedient method.

Endoscopic Closure of Gastrointestinal Fistulae and Leaks

The development of new endoscopic techniques, such as gastrointestinal (GI) stenting, full-thickness suturing, clip application, and use of tissue adhesives, has had a significant impact on management of GI fistulae. These techniques have shown promising results, but further study is needed to optimize the efficacy of long-term closure. The advancement of endoscopic techniques, including the use of the lumen apposing metal stent (LAMS), has allowed for the deliberate creation of fistula tracts to apply endoscopic therapy that previously could not be achieved. This article examines the rapidly evolving area of endoscopic fistula closure and its relationship to LAMS.

Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric surgery worldwide. Gastric sleeve stenosis is the most common postoperative complication, occurring in up to 3.9% of the cases. Current treatment options include endoscopic treatments, such as dilatations and stent placement as well as surgical revisions such as laparoscopic Roux-en-Y gastric bypass (LRYGB), wedge gastrectomy or seromyotomy.

METHODS

A retrospective analysis of our prospectively collected therapeutical endoscopy database was performed between January 2014 and February 2017. We included all cases of axial deviation or stenosis post LSG, which were treated endoscopically. Patients with concomitant sleeve leaks were excluded. Endoscopic interventions were performed under general anaesthesia and fluoroscopic assistance when needed. Sequential treatment with CRE balloons, achalasia balloons (30-40 mm) and fully covered stent placement for refractory cases was performed.

RESULTS

A total of 1332 LSG were performed. Overall, 27/1332 patients (2%) developed a gastric stenosis. All patients presented an axial deviation at the incisura angularis and 26% had a concomitant proximal stenosis. Successful endoscopic treatments were performed in 56% (15/27) of patients, 73% of the successful patients underwent a single dilatation procedure. All successful cases had a maximum of 3 interventions. The unsuccessful cases (44%) underwent LRYGB. Mean time between the primary surgery and the diagnosis of the stenosis was 10.3 months. Mean follow-up after the endoscopic treatment was 11.5 months. A stent migration was the only complication (3.7%) recorded.

CONCLUSIONS

Endoscopic treatment appears to be effective in 56% of patients with post-LSG stenosis. Only one session of achalasia balloon dilatation is necessary in 73% of successful cases. Pneumatic balloon dilatation seems to be a safe procedure in this patient population. Surgical revision into a LRYGB offers good outcomes in patients that have failed three consecutive endoscopic treatments.