Endoscopic vacuum therapy in salvage and standalone treatment of gastric leaks after bariatric surgery

Abstract

Introduction Gastric leaks constitute some of the most severe complications after obesity surgery. Resulting peritonitis can lead to inflammatory changes of the stomach wall and might necessitate drainage. The inflammatory changes make gastric leak treatment difficult. A common endoscopic approach of using stents causes the problem of inadequate leak sealing and the need for an external drainage. Based on promising results using endoscopic vacuum therapy (EVT) for esophageal leaks, we implemented this concept for gastric leak treatment after bariatric surgery (Ahrens et al., Endoscopy 42(9):693–698, 2010; Schniewind et al., Surg Endosc 27(10):3883–3890, 2013). Methods We retrospectively analyzed data of 31 gastric leaks after bariatric surgery. For leak therapy management, we used revisional laparoscopy with suturing and drainage. EVT was added for persistent leaks in sixteen cases and was used in four cases as standalone therapy. Results Twenty-one gastric leaks occurred in 521 sleeve gastrectomies (leakage rate 4.0%), 9 in 441 Roux-en-Y gastric bypasses (leakage rate 2.3%), and 1 in 12 mini-bypasses. Eleven of these gastric leaks were detected within 2 days after bariatric surgery and successfully treated by revision surgery. Sixteen gastric leaks, re-operated later than 2 days, remained after revision surgery, and EVT was added. Without revision surgery, we performed EVT as standalone therapy in 4 patients with late gastric leaks. The EVT healing rate was 90% (18 of 20). In 2 patients with a late gastric leak in sleeve gastrectomy, neither revisional surgery, EVT, nor stent therapy was successful. EVT patients showed no complications related to EVT during follow-up. Conclusion EVT is highly beneficial in cases of gastric leaks in obesity surgery where local peritonitis is present. Revisional surgery was unsuccessful later than 2 days after primary surgery (16 of 16 cases). EVT shows a similar healing rate to stent therapy (80–100%) but a shorter duration of treatment. The advantages of EVT are endoscopic access, internal drainage, rapid granulation, and direct therapy control. In compartmentalized gastric leaks, EVT was successful as a standalone therapy without external drainage.

Status of bariatric endoscopy–what does the surgeon need to know? A review

“…The EVT system positioning is based on endoscopic findings, and the intracavitary position should be used whenever there is an associated collection. Mechanisms of action include microdeformation and macrodeformation, improvement of perfusion (angiogenesis), control of local edema, and bacterial clearance[ 49 - 51 ].…”

Endoskopisches Komplikationsmanagment nach bariatrischen Operationen mit dem Fokus auf die aktuellen endoskopischen Therapien

“…OTSC Schlauchmagen [23,25] Gewebekleber Schlauchmagen/RYGB [23] TTS-Clips Schlauchmagen/RYGB [23] Gewebekleber Schlauchmagen [26] SEMS Schlauchmagen/RYGB [27,28,29] SEMS Schlauchmagen [30] Pigtail-Stents RYGB [31] VAC Schlauchmagen/RYGB [32,33] VAC Schlauchmagen [34] OTSC: Over the Scope Clip; TTS-Clip: Through the Scope Clip; SEMS: Selfexpanding Metal Stent; VAC: Vacuum-assisted Closure Damit man eine rationale Entscheidung für eine bestimmte Therapie wählen kann, hilft es, sich zu vergegenwärtigen, was mit den unterschiedlichen Therapien erreicht werden kann. Die 2 Therapieprinzipien sind Verschluss oder Drainage.…”

Endoscopic Management of Postoperative Esophageal and Upper GI Defects—A Narrative Review

“…Recent systematic reviews confirm high defect closure rates (81.6–85%) for these indications [ 67 , 68 ]. Less frequently EVT has also been proposed for the treatment of defects/leaks after bariatric surgery (staple line defects after laparoscopic sleeve gastrectomy and anastomotic defects after Roux en Y bypass) showing high healing rates up to 90% [ 69 , 70 , 71 , 72 ].…”