Is the Surgical Drainage Mandatory for Leak after Sleeve Gastrectomy?

INTRODUCTION

Despite the unanimous acknowledgement of the laparoscopic sleeve gastrectomy (LSG) worldwide, the leak remains its deficiency. For the last decade, the surgical treatment was practically considered mandatory for almost any collection following LSG. The aim of this study is to evaluate the need for surgical drainage for leak following LSG.

METHODS

All consecutive patients having gone through LSG from January 2017 to December 2020 were enrolled in our study. Once the demographic data and the leak history were registered, we analyzed the outcome of the surgical or endoscopic drainage, the characteristics of the endoscopic treatment, and the evolution to complete healing.

RESULTS

A total of 1249 patients underwent LSG and the leak occurred in 11 cases (0.9%). There were 10 women with a mean age of 47.8 years (27-63). The surgical drainage was performed for three patients and the rest of the eight patients underwent primary endoscopic treatment. The endoscopic treatment was represented with pigtails for seven cases and septotomy with balloon dilation for four cases. In two out of these four cases, the septotomy was anticipated by the use of a nasocavitary drain for 2 weeks. The average number of endoscopic procedures was 3.2 (range 2-6). The leaks achieved complete healing after an average duration of 4.8 months (range 1-9 months). No mortality was recorded for a leak.

CONCLUSIONS

The treatment of the gastric leak must be tailored to each patient. Although there is still no consensus for the endoscopic drainage of leaks after LSG, the surgical approach can be avoided in up to 72%. The benefits of pigtails and nasocavitary drains followed by endoscopic septotomy are undeniable, and they should be included in the armamentarium of any bariatric center.

Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series

AIM

Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS).

METHODS

All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence.

RESULTS

Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9).

CONCLUSIONS

Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.

Indwelling ureteric stents: Patterns of use and nomenclature

Objectives: To evaluate ureteric stenting practice patterns amongst a range of academic and community urologists, and to examine the nomenclature used to identify an indwelling ureteric stent from both our questionnaire and from a review of the literature.

Subjects and methods: A 16-question, peer-reviewed online survey was distributed to members of the Mid-Atlantic American Urological Association. Responses were collected over a 1-month period. Questions included demographics, ureteric stenting practice patterns, and utilization of stenting nomenclature. Inappropriate use of nomenclature was defined as a mismatch between the visually depicted stents and the written description amongst urologists. Trends in ureteric stenting and nomenclature usage were tabulated and analyzed.

Results: Of 863 members, 105 (12.2%) responded to the survey. There was a wide variety of practice settings, with the single-specialty group (44.2%) and academic/university (27.9%) being the two most common. Most providers used both cystoscopy and fluoroscopy to place stents (87.5%) as compared to fluoroscopy alone (12.5%). Most urologists (63.5%) removed stents with cystoscopy as compared to using a stent string (36.5%). While about half (51.0%) of the respondents left stents in situ for ≤3 months, many respondents (43.3%) felt comfortable with maximum dwell times of up to 6 months. The most commonly placed stent was the double pigtail stent (80.8%). However, most respondents inappropriately described this stent design as a Double J stent (72.1%). In the recent literature, 80% of articles clearly defined as using double pigtail stents, incorrectly identified their stent as a ‘Double J’.

Conclusions: Variations in ureteric stenting practice patterns exist amongst community and academic urologists. Although most urologists utilize double pigtail ureteric stents, the majority inaccurately identified this stent design as a Double J. We propose use of the term ‘indwelling ureteric stent’ (IUS) unless describing any specific stent design.

Ureteral stents: new ideas, new designs

Ureteral stents represent a minimally invasive alternative to preserve urinary drainage whenever ureteral patency is deteriorated or is under a significant risk to be occluded due to extrinsic or intrinsic etiologies. The ideal stent that would combine perfect long-term efficacy with no stent-related morbidity is still lacking and stent usage is associated with several adverse effects that limit its value as a tool for long-term urinary drainage. Several new ideas on stent design, composition material and stent coating currently under evaluation, foreseen to eliminate the aforementioned drawbacks of ureteral stent usage. In this article we review the currently applied novel ideas and new designs of ureteral stents. Moreover, we evaluate potential future prospects of ureteral stent development adopted mostly by the pioneering cardiovascular stent industry, focusing, however, on the differences between ureteral and endothelial tissue.