Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections

Abstract

Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage. We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies. Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 - 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded. Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods.

Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy

“…In 2016, Campos et al [27] defined their technique using argon plasma coagulation and Needle-Knife (Boston Scientific, Massachusetts, United States) for septum section in a female patient 60 days after LSG with resolution after two sessions. Mahadev et al [28] showed one of the most significant experiences in a multicenter study completed in the United States. The authors performed nine septotomies, using either Needle-Knife or argon plasma beam, with 66 % of resolution, and no adverse events related to the septotomy.…”

Endoscopic therapeutic interventions for management of postoperative bariatric surgery complications

“…These include prolonged duration of therapy (mean 23.5-50.7 days) owing to exchanging the sponge every 3-5 days until healing [28,31], which is associated with increased healthcare costs, hemorrhage, and considerable psychological distress [25,27,28,31]. Furthermore, diversion therapy with EVT or endoscopic internal drain has poor clinical success once a chronic fistula has been well established (>12 weeks) [32] as the probability of successful endoscopic diversion therapy decreases over time [33].…”

Seal or Drain? Endoscopic Management of Leaks Following Sleeve Gastrectomy

“…[1][2][3] Several techniques and devices have been described, mainly the use of fully covered metal stents (SEMS), clips, running sutures, double pigtail catheter placement, endoluminal vacuum therapy, and septotomy, all of which lead to a positive outcome rate ranging from 74% to 85%. [1][2][3] However, consensus regarding leakage treatment following sleeve gastrectomy has yet to be reached. 4 The treatment objectives are (a) rapid sepsis control, (b) healing of tissue defect, and (c) early return to oral intake.…”

“…At this location, intragastric drainage is short and direct compared with external drainage. 4 Furthermore, omentum presence in the area 739426S RIXXX10.1177/1553350617739426Surgical InnovationDonatelli et al editorial2017 1 Hôpital Privé des Peupliers, Paris, France 2 Institut Mutualiste Montsouris, Paris, France allows for collection organization and encapsulation, which is favorable to an internal drainage strategy.…”

“…Although they have been reported to allow for successful management of leaks, both have some inconveniences (prolonged therapy in endovacuum therapy and the required time interval between sleeve gastrectomy and septotomy. 1,2 However, these valid techniques that lead to pressure gradient reduction do not allow for associated management of an underlying stenosis.…”