Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy

Abstract

Background and study aims Sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. Leaks are the most feared complications after this procedure. Endoscopic septotomy has been described as a resolution technique that could be useful in the setting of late and chronic leaks. We present our experience in the management of gastric leaks with this advanced endoscopic technique. Patients and methods Retrospective review of patients who have been admitted to our hospital from January 2016 to December 2018. Results Five patients were found. All had their index surgery in outside hospitals. The average age was 51 years (range 40 – 69), and four patients were female. Mean time from LSG to leak presentation was 15 days (range 7 – 25). Mean time from leak presentation to septotomy procedure was 61 days (range 21 – 110). All patients were treated with sleeve dilatation before septotomy using endoscopic achalasia balloons. Mean procedure time was 79 minutes (range 55 – 125). Success was achieved in 80 % of patients, and no complications related to the procedure were identified. One patient underwent total gastrectomy for definitive management. Mean follow-up time was 14.25 months (range 6 – 26), and the average time for fistula closure was 60.25 days. Conclusion Endoscopic septotomy is safe and effective for management of chronic leaks after LSG. Associated non-selective dilatation may be a crucial step to allow distal patency and axis rectification for appropriate leak closure.

Endoscopic Management of Staple Line Leak after Bariatric Surgery: Surgeon’s Perspective

“…17 The OTSC system is also inappropriate for chronic fistulas with difficult-to-approximate fibrotic tissue. 18 Complications related to clipping (anchor migration, tear, etc.) are rare.…”

“…29 The success rate was reported to be 80% in a small case series in 2020 and 100% in another case series in 2017. 18,30 Argon plasma and needle knife as a cutting device have been used in previous reports, although any device with hemostatic technology can be applied. Septotomy requires multiple sessions and, accordingly, has also been called "progressive" endoscopic septotomy.…”

“…The number of sessions required for healing was reported to range from 1.8 to 5 sessions per patient. 18…”

Bariatric endoscopy: current primary therapies and endoscopic management of complications and other related conditions

“…They consider several sessions necessary to adequately drain the abscess cavity, as well as performing stricture dilation for better outcomes. This procedure represents a safe, feasible, and less invasive approach that should be strongly considered for the management of late and chronic postoperative leaks [42][43][44][45] . In our center, we prefer septotomy in combination with aggressive axis rectification using achalasia balloons.…”

Endoscopic therapeutic interventions for management of postoperative bariatric surgery complications

“…A mean of 2.3 (range 1-4) endoscopic septotomy procedures were performed with no serious adverse events reported. The endoscopic septotomy approach has been described by other groups as well, primarily in small case series with good clinical outcomes and minimal adverse events [32,[39][40][41][42][43]. It is important to note that in over 50% of patients with chronic leaks where septotomies were performed, there was concomitant stenosis at the angularis incisura that were all endoscopically dilated.…”