Treating sleeve gastrectomy leak with endoscopic stenting: the kuwaiti experience and review of recent literature

We would like to thank Donatelli et al. for the opportunity to comment on his complicated case report of a leak after laparoscopic sleeve gastrectomy (LSG) with a 2-cm-long dehiscence. We would like to make some remarks.In the selected case presented, a dehiscence of 2 cm is unusual and the technique used for the initial laparoscopic sleeve gastrectomy (LSG) must be questionable. A description of the initial procedure is suitable, describing the technique of dissection, the bougie size, the type of stapling, and the reinforcement used. Such a large defect can be explained by necrosis which occurred after dissection, by mischoice of stapling device, or/and poor choice of reinforcement type.The gastric leak healed by pigtails approach (although some may re-opened at a later date), but no details about the presence of gastric stenosis was mentioned. A twisted, poorly constructed sleeve will add insult to the injury and it necessitates the deployment of an endoscopic stent. Still the patient needed seven endoscopic sessions and 206 days to close the leak. In our proposed algorithm [1], for patients with gastric stenosis treated with tailored approach and endoscopic stent, the leaks achieved complete healing after an average duration of 118 days (a 75 % reduction in time). This difference of the healing time is increasing cost and patients' sufferance unnecessarily.The occurrence of a gastropleural fistula could also be explained by the presence of a concomitant hiatal hernia misrecognized during the initial procedure. If this was the case, it should have been operated contemporaneously and the gastropleural fistula could have been avoided. The OVESCO® clip (OTSC®; ) in this setting was, in fact, contraindicated.The authors Bbelieve^that in their experience, the stents will increase the local ischemia and subsequently increase leak in size. We do not agree with the statement that stents cause ischemia, as no recent data in the literature [2, 3] supports it.The debate on the algorithm regarding the leak size when no stenosis is associated will remain open. Most centers are proposing, for all types of leaks after LSG, an endoscopic stent [4,5]. The main purpose of the algorithm with our early experience of 19 cases was to change this dogma and to offer patients with this dreaded complication after LSG, a tailored approach. We remain unconvinced that pigtail drains represent a solution for all the types of leak, irrespective of leak size, and we are waiting for a new updated manuscript with all 200 cases from the authors. References1. Nedelcu M, Manus T, Cotirlet A et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. 2. Shim CN, Kim HI, Hyung WJ, et al. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc. 2014;28(3):833-40. 3. Alazmi W, Al-Sabah S, Ali DA, et al. Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature. ...

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“…We do not agree with the statement that stents cause ischemia, as no recent data in the literature [2,3] supports it.…”

contrasting

confidence: 61%

Pigtails Internal Drainage for 2-cm Gastric Leak After Sleeve Gastrectomy Prolongs Healing

Manos

Nedelcu

Noe͏̈l³

et al. 2015

OBES SURG

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“…Stenting may allow the patient to support their own nutritional needs with oral feeding during the healing process, potentially decreasing the overall duration of treatment [59]. The majority of patients treated with an endoluminal stent achieve complete healing with a success rate of 55-100% [58][59][60]63,83,98,[100][101][102][103][104][105][106][107][108][109][110][111][112]. Stenting often requires multiple endoscopies for stent replacement, or for the addition of other endoscopic adjuncts, over the course of treatment [59,101,106,108,113].…”

Section: Role Of Nonoperative Management Of Gi Leaks After Sgmentioning

confidence: 98%

ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management

Kim

Azagury

Eisenberg

et al. 2015

Surgery for Obesity and Related Diseases

178

107

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“…Klinik olarak stabil hastalarda kaçağın ilk hafta içinde tespiti ve endoskopik tedavisi başarı oranını artırır. 15 Ayrıca klinik olarak stabil hastalarda ikinci ameliyatın getireceği pulmoner emboli riski de göz önünde bulundurulmalıdır. Szewczyk ve ark.nın 565 LSG içeren çalışmasında SHK gelişen toplam 8 hastadan ilk 3'ünde laparotomi ile kaçak alanı onarılmış fakat 24-48 saat içinde kaçağın tekrarladığı görülmüştür.…”

Section: Stent Yerleşti̇ri̇lmesi̇unclassified

“…Güncel yayınlarda stent ile SHK'larının tam iyileşme oranı %50-100 arasında değişmekle birlikte genel başarı %80'in üzerinde-dir. 15 Ayrıca stent yerleştirilmesi sonrasında hastaların oral gıda alabilmesi poliklinik kontrolleri ile ayaktan takip edilebilmelerine imkan tanır.…”

Section: Stent Yerleşti̇ri̇lmesi̇unclassified

Treatment Of Staple Line Leaks After Laparoscopic Sleeve Gastrectomy With Self-Expandable Metalic Stents

Ece¹,

Yılmaz²,

Alptekın³

et al. 2016

Turkiye Klinikleri J Med Sci

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Ö ÖZ ZE ET T A Am ma aç ç: : Laparoskopik sleeve gastrektomi (LSG) kilo kaybı ve obezite ilişkili hastalıkların tedavisinde etkili bir bariatrik yöntemdir. LSG'nin en önemli komplikasyonu stapler hattı kaçakları-dır (SHK). Dörtyüz yirmi iki LSG olgusu içeren bu çalışmada SHK oranı ve tedavi yönetimi tartışılacaktır. G Ge er re eç ç v ve e Y Yö ön nt te em ml le er r: : Dörtyüz yirmi iki hastaya Ocak 2010-Haziran 2015 tarihleri arasında LSG uygulandı. Bir üniversite hastanesi obezite cerrahisi kliniğinde LSG sonrası kaçak teş-hisi konulan hastalar retrospektif olarak incelendi. Mide rezeksiyonu pilordan 4-6 cm mesafeden 60 mm stapler yardımı ile yapıldı. Mide tüpü 36F buji ile kalibre edildi. Stapler hattı rutin olarak devamlı dikişlerle kuvvetlendirildi. SHK gelişen hastalar genişleyebilen stentler ile tedavi edildi. B Bu ul lg gu ul la ar r: : Hastaların ortalama yaşı 41.8 (29-55) yıl ve kadın/erkek oranı 7/5 idi. Ortalama beden kitle indeksi 44.1 kg/m2 olan hastalardan birisinde gastrik band ameliyatı hikayesi vardı. Stapler hattı kaçak oranı 12/422 (%2.8) idi. Tüm olgularda kaçak alanı gastroözofajiyal bileşke komşulu-ğunda idi. SHK endoskopik genişleyebilen stent uygulaması ile tedavi edildi. Tüm hastalarda parenteral beslenme ve antibiyotikleri içeren medikal destek sağlandı. Tüm olgularda stent yerleştirilmesi başarılı bir tedavi sağladı. S So on nu uç ç: : Laparoskopik sleeve gastrektomide SHK en sık gö-rülen komplikasyon olup tüm komplikasyonların yarısını oluşturur. Genişleyebilen stent uygulaması, antibiyotik ve parenteral beslenme ile birleştirildiğinde etkili sonuçlar elde edilebilir ve durumu stabil hastalarda ilk tedavi basamağı olmalıdır.A An na ah ht ta ar r K Ke el li im me el le er r: : Laparoskopi; obezite, morbid; anastomotik sızıntı; stentler A AB BS ST TR RA AC CT T O Ob bj je ec ct ti iv ve e: : Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure on weight loss and obesity-related comorbidities. The most important complication of LSG is the staple line leaks (SLL). This study aims to report the SLL rate and its management with self-expandable stent in a series of 422 LSGs. M Ma at te er ri ia al l a an nd d M Me et th ho od ds s: : A total of 422 patients underwent LSG from January 2010 to June 2015. A retrospective study was performed to the patients who were diagnosed as staple line leak at department of obesity surgery of a university hospital. The gastric resection was started from the antrum with a distance of 4-6 cm to the pilorus, by a 60mm staples. A 36F bougie was used to calibrate the gastric tube. The staple line was routinely reinforced with running sutures. The patients who developed SLL were treated endoscopically with self-expandable metalic stent (SEMS) placement. R Re es su ul lt ts s: : The mean age of patients were 41.8 (29-55) years, and female/male ratio was 7/5. Mean body mass index of 44.1 kg/m2 in patients, one of the cases has a gastric banding history. SLL rate was 12/422 (2.8%). Leak area was near the gastroesophageal junction in all cases. ...

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Treating sleeve gastrectomy leak with endoscopic stenting: the kuwaiti experience and review of recent literature

Cited by 67 publications

References 9 publications

Pigtails Internal Drainage for 2-cm Gastric Leak After Sleeve Gastrectomy Prolongs Healing

Pigtails Internal Drainage for 2-cm Gastric Leak After Sleeve Gastrectomy Prolongs Healing

ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management

Treatment Of Staple Line Leaks After Laparoscopic Sleeve Gastrectomy With Self-Expandable Metalic Stents

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