Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort

Smith, Zachary L.; Park, Kenneth H.; Llano, Ernesto M.; Donboli, Kianoush; Fayad, Lea; Han, Samuel; Kang, Lorna; Simril, Robert T.; Patel, Riddhi S.; Hollander, Thomas; Rogers, Melinda; Elmunzer, B. Joseph; Siddiqui, Uzma D.; Aadam, A. Aziz; Mullady, Daniel; Lang, Gabriel; Das, Koushik K.; Jamil, Laith H.; Lo, Simon K.; Gaddam, Srinivas; Chapman, Christopher G.; Keswani, Rajesh N.; Wani, Sachin; Coté, Gregory A.; Kumbhari, Vivek; Kushnir, Vladimir

doi:10.1016/j.soard.2019.04.009

Cited by 17 publications

(10 citation statements)

References 31 publications

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“…abdominal pain in 15-97% of patients and removal in 11-15% [15,16,36,37,39]). Bleeding and perforation are also recognised complications of stenting, with incidences in the literature [25,27,32,43] ranging respectively from 0 to 11.8% and from 0 to 8.4%. These complications were not encountered in our patients.…”

Section: Discussionmentioning

confidence: 99%

“…The studies performed to date have included heterogenous patient cohorts, examined the efficacy of stent placement for a variety of indications and lacked standardisation [ 25 ]. As a result, there is no firm evidence base which can be used determine which stent treatment is optimal [ 26 , 27 ] in order to achieve the best clinical outcomes and to avoid the need for long-term E-Vac therapy.…”

Section: Introductionmentioning

confidence: 99%

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Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

et al. 2021

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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. Graphical Abstract

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

et al. 2021

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“…Surgical management also has a role as a step up, escalation therapy, when more conservative treatments fail 199,216. In hemodynamically stable patients a trial of nonsurgical interventions should be attempted for at least 3 months before considering surgery 47,68,188,195,217,218. Surgical approach is preferred after 6 months of failure with conservative methods, because the probability of healing following endoscopic treatment is significantly decreased (from 76.4% at 1 mo to 48.5% at 6 mo) 197.…”

Section: Surgical Managementmentioning

confidence: 99%

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

Gjeorgjievski¹,

Imam

Cappell

et al. 2020

Journal of Clinical Gastroenterology

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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.

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“…12,13 Endoscopic stenting has been the most popular technique used and continues to have a high rate of healing the leak around 70% to 80%. 14,15 Endoscopic vacuum therapy (EVAC) has also shown promise with similar healing rates, 16,17 and actually, has been shown to be more effective than stenting. 18 Given the location of the leak, and its difficult accessibility, drainage with internal drainage catheters has been studied with good outcomes that mirror these other endoscopic methods.…”

Section: Introductionmentioning

confidence: 99%

Esophagojejunostomy or Fistulojejunostomy Are Safe Salvage Operations for Bariatric Surgery Leaks

Leeds

Kerlee

Fair

et al. 2023

Foregut: The Journal of the American Foregut Society

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Background: Sleeve gastrectomy is the most commonly performed bariatric surgery, and staple line leaks occur in 1% or less of patients. Gastric bypass is still a common weight loss surgery with a leak rate of 2%. Definitive surgical management of the leak is mainly accomplished with esophagojejunostomy or fistulojejunostomy. Proceeding with surgical management of these leaks is poorly understood given the rare need and high risk. We reviewed our outcomes of definitive surgical management for leaks following weight loss surgery. Methods: An institutional review board approved database identified patients undergoing definitive surgical management for bariatric surgery leaks with either an esophagojejunostomy or fistulojejunostomy. Initial data that led to the leak, intraoperative factors, and postoperative outcomes were collected. Primary endpoint was leak after definitive surgical procedure. Results: A database of 87 patients was queried to find 22 patients undergoing surgery. Twelve patients underwent esophagojejunostomy and 10 patients underwent fistulojejunostomy. There was a mean of 90 days to leak recognition. There was a mean of 228 days from first endoscopic procedure to definitive surgery in the 18 patients undergoing initial endoscopic management. The mean time from the sentinel surgery to definitive surgery was 296 days. There were 6 patients (27%) that had subsequent leaks after definitive surgery. All subsequent leaks healed with endoscopic therapy. No deaths occurred. Conclusion: Bariatric surgery leaks are difficult to manage. When endoscopic management fails, esophagojejunostomy, and fistulojejunostomy are safe and feasible salvage options. Additional leaks following these salvage operations can occur in up to 27% of patients.

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Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort

Cited by 17 publications

References 31 publications

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

Esophagojejunostomy or Fistulojejunostomy Are Safe Salvage Operations for Bariatric Surgery Leaks

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