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1
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Achi N, Wang H, Hao J, Chen W. Innovative Approaches to Managing Postoperative Complications in Laparoscopic Sleeve Gastrectomy: A Scoping Review. J Laparoendosc Adv Surg Tech A 2025; 35:6-14. [PMID: 39504988 DOI: 10.1089/lap.2024.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2024] Open
Abstract
Background: Laparoscopic sleeve gastrectomy (LSG) is an effective surgical intervention for obesity, but managing complications post LSG remains crucial. Given the global prevalence of obesity, innovative approaches are needed to improve patient outcomes. Objective: This scoping review aimed to comprehensively map the existing literature on innovative approaches for managing complications in adult patients undergoing LSG to treat morbid obesity. This management strategy may include surgical techniques, perioperative care, nutritional support, or other relevant strategies. Methods: A systematic search of PubMed and Scopus databases was conducted to identify relevant studies. The prespecified inclusion criteria were applied through a two-stage screening process. Studies involving adult patients who underwent LSG for morbid obesity (body mass index > 35) and those investigating interventions related to complications were included. The scoping review process adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The results were summarized using a narrative approach. Results: This review included 31 studies with 4547 participants, showing diverse study designs, patient demographics, and surgical locations. Among them, 6 were case reports, 18 were randomized controlled trials, and 7 were retrospective studies. Complications of LSG include staple-line leaks, stenosis, hemorrhage, infection, gastric volvulus, and nutrient malabsorption. Innovative interventions, such as staple-line reinforcement, plication methods, and the Over-the-Scope Clip system, have been investigated for effective management. Conclusion: This scoping review provides valuable insights into innovative interventions for managing complications post LSG. This review highlights the need for further research to explore long-term outcomes, compare different interventions, and address the existing gaps in the literature.
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Affiliation(s)
- Ntiak Achi
- Graduate Department of Shanxi Medical University, Taiyuan, China
| | - Huanhuan Wang
- Graduate Department of Shanxi Medical University, Taiyuan, China
| | - Jinjin Hao
- Graduate Department of Shanxi Medical University, Taiyuan, China
| | - Wenliang Chen
- Department of General Surgery, The 2nd Affiliated Hospital of Shanxi Medical University, Taiyuan, China
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2
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Shenoy A, Schulman AR. Endoscopic Management of Bariatric Surgery Complications: Fistulas, Leaks, and Ulcers. Gastrointest Endosc Clin N Am 2024; 34:655-669. [PMID: 39277297 DOI: 10.1016/j.giec.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
Bariatric surgery is a safe and effective treatment option for patients with obesity and obesity-related comorbidities, with Roux-en-Y gastric bypass and sleeve gastrectomy being the two most common procedures. Despite the success of these interventions, adverse events are not uncommon. Endoscopic management has become first-line therapy when complications occur, and the armamentarium of devices and techniques continues to grow. This article focuses on the management of fistulas, leaks, and ulcers and also focuses on the etiology and endoscopic management strategy of each complication.
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Affiliation(s)
- Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA. https://twitter.com/abhi2shenoy
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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3
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Farah A, Malshy K, Tatakis A, Abboud W, Mari A, Sayida S. Nonoperative Management Strategies for Anastomotic Leaks After One Anastomosis Gastric Bypass (OAGB): A Literature Review. Cureus 2024; 16:e69708. [PMID: 39429265 PMCID: PMC11489929 DOI: 10.7759/cureus.69708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2024] [Indexed: 10/22/2024] Open
Abstract
One Anastomosis Gastric Bypass (OAGB) has gained widespread acceptance as an effective bariatric surgery due to its relative simplicity and favorable outcomes in weight loss and metabolic improvement. However, anastomotic leaks, though uncommon, present a significant complication with the potential for severe morbidity and mortality if not managed appropriately. This review examines the range of nonoperative strategies currently employed to manage anastomotic leaks and fistulae following OAGB. The focus is on endoscopic techniques, including the use of clips, stents, suturing systems, internal drainage, vacuum therapy, and tissue sealants, which have been successfully used in various gastrointestinal surgeries. Although a proportion of patients will require surgical treatments, these strategies offer less invasive alternatives to surgical intervention and can be tailored to the specific characteristics of the leak and patient condition. However, the application of these techniques specifically for OAGB-related leaks is not as well-documented. This review lists the available evidence on these nonoperative approaches, highlighting some of their potential benefits and limitations. While these methods show promise, there is a clear need for further research to establish standardized protocols and optimize their use in the context of OAGB-related leaks and fistulae.
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Affiliation(s)
- Amir Farah
- General Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Kamil Malshy
- Urology, University of Rochester Medical Center, Rochester, USA
| | - Anna Tatakis
- General Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Wisam Abboud
- General Surgery, Edinburgh Medical Missionary Society (EMMS) Nazareth Hospital, Nazareth, ISR
| | - Amir Mari
- Gastroenterology and Hepatology, Edinburgh Medical Missionary Society (EMMS) Nazareth Hospital, Nazareth, ISR
| | - Sa'd Sayida
- General Surgery, Edinburgh Medical Missionary Society (EMMS) Nazareth Hospital, Nazareth, ISR
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4
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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5
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Medas R, Rodrigues-Pinto E. Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks. Gastroenterol Res Pract 2023; 2023:9712555. [PMID: 37342388 PMCID: PMC10279499 DOI: 10.1155/2023/9712555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/20/2022] [Accepted: 11/25/2022] [Indexed: 06/22/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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6
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Negm S, Mousa B, Shafiq A, Abozaid M, Allah EA, Attia A, AbdelKader T, Farag A. Endoscopic management of refractory leak and gastro-cutaneous fistula after laparoscopic sleeve gastrectomy: a randomized controlled trial. Surg Endosc 2023; 37:2173-2181. [PMID: 36326931 PMCID: PMC10017559 DOI: 10.1007/s00464-022-09748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Gastro-cutaneous fistula is a rare complication after laparoscopic sleeve gastrectomy (LSG) with incidence of occurrence 1-2%. Most of gastro-cutaneous fistulae do not respond to conservative management and need intervention either surgically or endoscopically. METHODS This prospective randomized clinical study included referred patients who had LSG performed at our department or other centers, and complicated with post-LSG leak or gastro-cutaneous fistula between December/2019 and March/2021. Included patients were ASA Physical status I-II. Primary and secondary outcomes were recurrence of the fistula and mortality in each group after the intervention during the 18 months follow-up period, respectively. RESULTS Thirty patients were randomized into two groups: Surgery Group (SG, n = 15) and Endoscopy Group (EG, n = 15). Mean age of patients was 42.3 ± 8.7 and 42.6 ± 8.3 years-old in SG and EG, respectively. Females constituted 73.3% and 80% in SG and EG, respectively. Median time-to-gastric leak post LSG was six (range: 4-7) days in both groups. SG patients were surgically managed with primary repair of the gastric fistula and gastrojejunostomy in 13 patients or converting SG into Roux-en-Y gastric bypass in two patients, while EG patients were endoscopically managed with stitching, stenting, stenting and dilation, and clipping and dilation in 5, 4, 4 and 2 patients, respectively. Incidence of recurrent leak during 1st week was significantly higher in SG than EG (p < 0.001). No mortality reported in EG, while 2 patients died in SG (p = 0.48). CONCLUSION Endoscopic intervention may offer a successful modality in managing post-LSG gastric leak and gastro-cutaneous fistula that do not respond to conservative measures in stable patients.
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Affiliation(s)
- Said Negm
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Bassam Mousa
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Shafiq
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Abozaid
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ehab Abd Allah
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Adel Attia
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Taha AbdelKader
- grid.415762.3Shepeen alkom teaching hospital, Ministry of health, Monufia, Egypt
| | - Ahmed Farag
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
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7
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Madrigal Méndez AL, Grant D, Hernández V, Ernest-Suárez K, Vargas-Madrigal J, Arguedas LD, Villalobos Á. Management of multiple esophageal leaks with an ultra-large fully covered metallic stent after aborted peroral endoscopic myotomy. Endoscopy 2023; 55:E478-E479. [PMID: 36858346 PMCID: PMC9977564 DOI: 10.1055/a-2018-4213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
| | - Daniela Grant
- Gastroenterology, Caja Costarricense de Seguro Social, San José, Costa Rica
| | - Viviana Hernández
- Gastroenterology, Caja Costarricense de Seguro Social, San José, Costa Rica
| | - Kenneth Ernest-Suárez
- Gastroenterology, Caja Costarricense de Seguro Social, San José, Costa Rica,University of Costa Rica, Faculty of Sciences, San José, Costa Rica
| | - Jorge Vargas-Madrigal
- Gastroenterology Department, Hospital Enrique Baltodano Briceño, Liberia, Costa Rica
| | | | - Álvaro Villalobos
- Gastroenterology, Caja Costarricense de Seguro Social, San José, Costa Rica
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8
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Binda C, Jung CFM, Fabbri S, Giuffrida P, Sbrancia M, Coluccio C, Gibiino G, Fabbri C. Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:136. [PMID: 36676760 PMCID: PMC9864982 DOI: 10.3390/medicina59010136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Paolo Giuffrida
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
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9
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De Simone B, Chouillard E, Ramos AC, Donatelli G, Pintar T, Gupta R, Renzi F, Mahawar K, Madhok B, Maccatrozzo S, Abu-Zidan FM, E Moore E, Weber DG, Coccolini F, Di Saverio S, Kirkpatrick A, Shelat VG, Amico F, Pikoulis E, Ceresoli M, Galante JM, Wani I, De' Angelis N, Hecker A, Sganga G, Tan E, Balogh ZJ, Bala M, Coimbra R, Damaskos D, Ansaloni L, Sartelli M, Pararas N, Kluger Y, Chahine E, Agnoletti V, Fraga G, Biffl WL, Catena F. Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines. World J Emerg Surg 2022; 17:51. [PMID: 36167572 PMCID: PMC9516804 DOI: 10.1186/s13017-022-00452-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/16/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. METHOD A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. CONCLUSIONS The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France.
| | - Elie Chouillard
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France
| | - Almino C Ramos
- GastroObesoCenter Institute for Metabolic Optimization, Sao Paulo, Brazil
| | - Gianfranco Donatelli
- Interventional Endoscopy and Endoscopic Surgery, Hôpital Privé Des Peupliers, Paris, France
| | - Tadeja Pintar
- Department of Abdominal Surgery, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Rahul Gupta
- Division of Minimally Invasive Surgery and Bariatrics, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Federica Renzi
- General Surgery and Trauma Team, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milano, Milan, Italy
| | - Kamal Mahawar
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Brijesh Madhok
- East Midlands Bariatric and Metabolic Institute, University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | - Stefano Maccatrozzo
- Department of Bariatric Surgery, Istituto Di Cura Beato Matteo, Vigevano, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Salomone Di Saverio
- Department of Surgery, Madonna Del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Andrew Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Francesco Amico
- Department of Surgery, John Hunter Hospital and The University of Newcastle, Newcastle, MSW, Australia
| | - Emmanouil Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Joseph M Galante
- University of California, Davis 2315 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Nicola De' Angelis
- Service de Chirurgie Digestive Et Hépato-Bilio-Pancréatique - DMU CARE, Hôpital Henri Mondor, Paris, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Edward Tan
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Dimitrios Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, Pavia, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Nikolaos Pararas
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Elias Chahine
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France
| | - Vanni Agnoletti
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Gustavo Fraga
- School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Walter L Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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10
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Lafeuille P, Wallenhorst T, Lupu A, Jacques J, Lambin T, Camus M, Yzet C, Ponchon T, Rostain F, Rivory J, Subtil F, Pioche M. Endoscopic submucosal dissection combined with clip for closure of gastrointestinal fistulas including those refractory to previous therapy. Endoscopy 2022; 54:700-705. [PMID: 34500487 DOI: 10.1055/a-1641-7938] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Gastrointestinal (GI) fistula is a life-threatening condition and a therapeutic challenge. Endoscopic approaches include mucosal abrasion, clip closure, or stent diversion, with moderate success rates in the long term. We assessed whether fistula endoscopic submucosal dissection with clip closure (FESDC) could lead to complete resolution of fistulas even after failure of previous endoscopic therapy. METHODS Patients with GI fistulas, including those with previous failed treatment, were retrospectively included. The primary outcome was long-term (> 3 months) success of fistula healing. Secondary outcomes included technical success, safety, and factors associated with FESDC success. RESULTS 23 patients (13 refractory 57 %) were included. Tight immediate sealing was achieved in 19 patients (83 %; 95 % confidence interval [CI] 61 %-95 %). Long-term closure was achieved in 14 patients (61 %; 95 %CI 39 %-80 %), with median follow-up of 20 months. Complications occurred in two patients (9 %). Previous local malignancy (P = 0.08) and radiotherapy (P = 0.047) were associated with a higher risk of failure. CONCLUSION This novel FESDC strategy was demonstrated to be safe and feasible for permanent endoscopic closure of GI fistulas. Further studies are warranted to determine the place of this technique in the management of chronic GI fistula.
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Affiliation(s)
- Pierre Lafeuille
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | - Timothée Wallenhorst
- Department of Gastroenterology and Endoscopy, Pontchaillou University Hospital, Rennes, France
| | - Alexandru Lupu
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | - Jérémie Jacques
- Department of Gastroenterology and Endoscopy, Dupuytren University Hospital, Limoges, France
| | - Thomas Lambin
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | - Marine Camus
- Department of Gastroenterology and Endoscopy, Saint Antoine Hospital, Paris, France
| | - Clara Yzet
- Department of Gastroenterology and Endoscopy, Amiens University Hospital, Amiens, France
| | - Thierry Ponchon
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | - Florian Rostain
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | - Jérôme Rivory
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
| | - Fabien Subtil
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France
| | - Mathieu Pioche
- Department of Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France
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11
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Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc 2022; 34:43-62. [PMID: 34115407 DOI: 10.1111/den.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.
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Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kitty Kit Ying Auyeung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Siu Fung Lam
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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12
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Gjeorgjievski M, Imam Z, Cappell MS, Jamil LH, Kahaleh M. A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks. J Clin Gastroenterol 2021; 55:551-576. [PMID: 33234879 DOI: 10.1097/mcg.0000000000001451] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
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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Affiliation(s)
- Mihajlo Gjeorgjievski
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Zaid Imam
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mitchell S Cappell
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Laith H Jamil
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
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13
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Hany M, Ibrahim M, Zidan A, Samir M, Elsherif A, Selema M, Sharaan M, Elhashash M. Role of Primary Use of Mega Stents Alone and Combined with Other Endoscopic Procedures for Early Leak and Stenosis After Bariatric Surgery, Single-Institution Experience. Obes Surg 2021; 31:2050-2061. [PMID: 33409972 DOI: 10.1007/s11695-020-05211-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Surgical therapy for post-bariatric surgery complications is associated with significant morbidity and mortality. Endoscopic options like primarily endoscopically placed fully covered self-expandable metallic stents (SEMS) offer significant benefits for the management of leaks and obstructions or stenosis, and even in case of mega stent failure, further endoscopic techniques could resolve the situation. MATERIALS AND METHODS We conducted a single-centre retrospective study on patients with leakage and stenosis/obstruction after bariatric surgery who were managed primarily by SEMS between January 2015 and January 2019. Clinical success rate was evaluated in terms of the cure of the reason for stenting, the need for other interventions, and the presentation of stent-related complications. RESULTS There were 58 patients included, (50 with leak, 8 with stenosis/obstruction following bariatric surgery). Mean time to stent placement was 6.82 (±1.64) days for the leak group and 35 (±21.13) days for the stenosis group (p = 0.019). Successful outcomes with SEMS alone were achieved in 42 (72.41%) patients, while 16 patients had failed SEMS treatment, of whom 14 were successfully managed by endoscopic procedures while two cases needed surgical intervention. Of the SEMS-related complications encountered, 25.86% were ulcers; 24.13%, vomiting; 22.41%, gastroesophageal reflux disease (GerdQ≥8); 18.96%, stent migration; and 5.17%, stent intolerance. CONCLUSION A mega stent is an effective and safe tool for the early management of post-bariatric surgery leakage and stenosis, and it is associated with acceptable rates of failure that can be managed by further endoscopic techniques in most of the patients.
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Affiliation(s)
- Mohamed Hany
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt.
| | - Mohamed Ibrahim
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Ahmed Zidan
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Samir
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Amr Elsherif
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Selema
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Sharaan
- Department of Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohamed Elhashash
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
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Use of Argon Plasma Coagulation and Endoscopic Hemoclips for Postsurgical Gastrointestinal Fistula. Case Rep Gastrointest Med 2020; 2020:8835437. [PMID: 33224539 PMCID: PMC7673945 DOI: 10.1155/2020/8835437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/01/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022] Open
Abstract
A 72-year-old male was diagnosed with a duodenal mass and underwent extensive surgical resection. The patient's post-op course was complicated by an anastomotic leak that was first treated conservatively; however, his condition continued to deteriorate. An upper endoscopy was performed, which showed misplacement of drain forming a fistulous track through the lumen of the bowel. We removed the drain and used argon plasma coagulation to de-epithelize the lumen and closed the fistula with hemostasis clips. The patient's clinical status improved significantly. Our case emphasizes the success of endoscopic techniques as an alternative option in the management of postsurgical anastomotic leaks and fistulas in the right clinical setting and patient population.
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15
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Gastric Fistula After Sleeve Gastrectomy: Clinical Features and Treatment Options. Obes Surg 2020; 31:1196-1203. [PMID: 33222105 DOI: 10.1007/s11695-020-05115-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To trace the clinical profile of fistula cases after sleeve gastrectomy (SG) and evaluate the efficacy and safety of endoscopic treatments and the admission costs of these patients. METHODS This is a retrospective study of patients who developed gastric fistulas after SG. All patients were submitted to surgical and/or endoscopic interventions (self-expandable stent, septotomy, and balloon dilation). The main studied variables were need for reoperation, number of endoscopic procedures, endoscopic complications, time until fistula diagnosis, fistula location, time until resolution, length of hospital stay, and health costs. RESULTS The sample was mainly female (76.2%) with a mean age of 39.5 years and a BMI of 39.6 kg/m2. In 90.5% of cases, the fistula occurred in the topography of the His angle. Thirteen patients required surgical intervention. Of the patients who underwent endoscopic interventions, it was necessary to place more than one self-expandable stent of a maximum duration of 4 weeks. Six patients underwent more than two sessions of septotomy. There was one case of bleeding after septotomy. Dilatation was required in 71.4% of patients and an average of two sessions (1-5) per patient. The diagnosis of fistula occurred 14.4 days after surgery. The average time to resolve fistulas was 50.6 days. The average hospital stay was 75.8 days. The total cost of hospitalization was on average US$ 75,180.00. CONCLUSION The surgical and endoscopic treatment of gastric fistulas after SG was safe and effective. There was a very low rate of complications. The time of onset of fistulas was not decisive for patient improvement.
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16
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Liu S, Yheulon CG. Comment on: Insights into the treatment of postsleeve gastrectomy leak. Analysis of the results of 105 cases on a national register. Surg Obes Relat Dis 2020; 17:44-45. [PMID: 33208268 DOI: 10.1016/j.soard.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/03/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Shinban Liu
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Christopher G Yheulon
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
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17
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Iglesias Jorquera E, Egea Valenzuela J, Serrano Jiménez A, Carrilero Zaragoza G, Ortega Sabater A, Sánchez Velasco E, Ruiz de Angulo D, Munitiz V, Parrilla P, Alberca de Las Parras F. Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:14-22. [PMID: 33118355 DOI: 10.17235/reed.2020.6821/2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option. AIMS the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks. METHODS a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018. RESULTS twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach. CONCLUSIONS endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.
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Affiliation(s)
| | - Juan Egea Valenzuela
- Aparato Digestivo , Hospital Clínico Universitario Virgen de la Arrixaca, España
| | | | | | | | | | | | - Vicente Munitiz
- Cirugía, Hospital Clinico Universitario Virgen de la Arrixaca
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18
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Cereatti F, Grassia R, Drago A, Conti CB, Donatelli G. Endoscopic management of gastrointestinal leaks and fistulae: What option do we have? World J Gastroenterol 2020; 26:4198-4217. [PMID: 32848329 PMCID: PMC7422542 DOI: 10.3748/wjg.v26.i29.4198] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.
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Affiliation(s)
- Fabrizio Cereatti
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Roberto Grassia
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Andrea Drago
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Clara Benedetta Conti
- Digestive Endoscopy and Gastroenterology Unit, Cremona Hospital, Cremona, Cremona 26100, Italy
| | - Gianfranco Donatelli
- Department of Interventional Endoscopy, Hospital Prive Peupliers, Ramsay Santé, Paris 75013, France
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19
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Endoscopic internal drainage by double pigtail stents in the management of laparoscopic sleeve gastrectomy leaks. Surg Obes Relat Dis 2020; 16:831-838. [DOI: 10.1016/j.soard.2020.03.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/17/2022]
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20
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Endoscopic management of refractory leaks and fistulas after bariatric surgery with long-term follow-up. Surg Endosc 2020; 35:2715-2723. [DOI: 10.1007/s00464-020-07702-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022]
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21
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Bona D, Giovannelli A, Micheletto G, Campanelli G, Cavalli M, Bonitta G, Aiolfi A. Treatment of Persistent Leaks After Laparoscopic Sleeve Gastrectomy with the Simultaneous Over-the-Scope Clip (OTSC) and Mega Stent Strategy. Obes Surg 2020; 30:3615-3619. [DOI: 10.1007/s11695-020-04590-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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22
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Vedantam S, Roberts J. Endoscopic Stents in the Management of Bariatric Complications: Our Algorithm and Outcomes. Obes Surg 2019; 30:1150-1158. [DOI: 10.1007/s11695-019-04284-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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24
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 303] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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25
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Comment on "Incidence and efficacy of Stent Placement in Leak Management After Bariatric Surgery: an MBSAQIP Analysis". Ann Surg 2019; 270:e82-e83. [PMID: 31188227 DOI: 10.1097/sla.0000000000003243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smith ZL, Park KH, Llano EM, Donboli K, Fayad L, Han S, Kang L, Simril RT, Patel R, Hollander T, Rogers MC, Elmunzer BJ, Siddiqui UD, Aadam AA, Mullady DK, Lang GD, Das KK, Jamil LH, Lo SK, Gaddam S, Chapman CG, Keswani RN, Wani S, Cote GA, Kumbhari V, Kushnir VM. Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort. Surg Obes Relat Dis 2019; 15:850-855. [DOI: 10.1016/j.soard.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/06/2019] [Accepted: 04/06/2019] [Indexed: 02/07/2023]
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Al-Lehibi A. Endoscopic Management of Gastrobronchial Fistula after Laparoscopic Sleeve Gastrectomy: A Case Report. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 7:106-109. [PMID: 31080391 PMCID: PMC6503693 DOI: 10.4103/sjmms.sjmms_160_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Bariatric surgery has rapidly emerged as a modality for managing morbid obesity; however, despite being considered safe, some complications do exist. Formation of a gastrobronchial fistula is a rare complication of laparoscopic sleeve gastrectomy that is associated with high morbidity and mortality. Nowadays, novel endoscopic techniques have widely been adopted in the management of such cases, as they provide minimally invasive options that decrease the morbidity and mortality. Here, the author presents a report of a middle-aged, morbidly obese male who had previously undergone laparoscopic sleeve gastrectomy and returned with a 3-month history of productive cough. On upper gastrointestinal series, the patient was found to have a fistula communicating the stomach to the bronchial tree of his left lung (gastrobronchial fistula). He was treated with endoscopic fistula closure using an over-the-scope clip and a fully-covered Niti-S metallic stent. After this treatment, the patient's symptoms improved dramatically, and the stent was successfully removed 12 weeks later. This report highlights the management of a patient with gastrobronchial fistula formation following laparoscopic sleeve gastrectomy as well as provides a literature review of using combined endoscopic management to treat gastrobronchial fistulas.
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Affiliation(s)
- Abed Al-Lehibi
- Department of Gastroenterology, King Fahad Medical City, Riyadh, Saudi Arabia
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Gastroseal: A Novel Stent Design for the Management of Post-Bariatric Surgery Leaks. ACG Case Rep J 2019; 5:e85. [PMID: 30775388 PMCID: PMC6358575 DOI: 10.14309/crj.2018.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/21/2018] [Indexed: 11/23/2022] Open
Abstract
Bariatric surgery leaks remain a dreaded complication with ominous consequences. Fully covered stents have shown efficacy in the treatment of leaks; however, stent migration remains a major drawback. Ultra-large stents have shown reduced rates of migration and coapt better against the walls, but deep ulcers occur in almost all patients, as well as frequent severe intolerance, bleeding, and perforation. We have developed a large expandable stent with physical characteristics and a particularly flexible mesh design that make it much less traumatic than conventional large stents while maintaining the advantage of being less prone to migration. In this patient with a post-sleeve gastrectomy leak, we provide a proof of concept that the Gastroseal stent is effective and nontraumatic despite its very large size.
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Singh RR, Nussbaum JS, Kumta NA. Endoscopic management of perforations, leaks and fistulas. Transl Gastroenterol Hepatol 2018; 3:85. [PMID: 30505972 DOI: 10.21037/tgh.2018.10.09] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/19/2018] [Indexed: 12/14/2022] Open
Abstract
The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.
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Affiliation(s)
- Ritu Raj Singh
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeremy S Nussbaum
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil A Kumta
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Okazaki O, Bernardo WM, Brunaldi VO, Junior CCDC, Minata MK, de Moura DTH, de Souza TF, Campos JM, Santo MA, de Moura EGH. Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2018; 28:1788-1796. [PMID: 29654447 DOI: 10.1007/s11695-018-3236-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.
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Affiliation(s)
- Ossamu Okazaki
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil.
| | - Wanderley M Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Vitor O Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Cesar C de Clemente Junior
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Maurício K Minata
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Diogo T H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | - Thiago F de Souza
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
| | | | - Marco Aurélio Santo
- Bariatric and Metabolic Surgery Unit, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Eduardo G H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of São Paulo Medical School, Dr. Arnaldo Av, 255., São Paulo, 01246-903, Brazil
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Efficacy and Safety of the Over-the-Scope Clip (OTSC) System in the Management of Leak and Fistula After Laparoscopic Sleeve Gastrectomy: a Systematic Review. Obes Surg 2018; 27:2410-2418. [PMID: 28353180 DOI: 10.1007/s11695-017-2651-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. OBJECTIVES This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. METHODS PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. RESULTS A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). CONCLUSION OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.
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Martin del Campo SE, Mikami DJ, Needleman BJ, Noria SF. Endoscopic stent placement for treatment of sleeve gastrectomy leak: a single institution experience with fully covered stents. Surg Obes Relat Dis 2018; 14:453-461. [DOI: 10.1016/j.soard.2017.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 12/04/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
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Cosse C, Rebibo L, Brazier F, Hakim S, Delcenserie R, Regimbeau JM. Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy. Br J Surg 2018; 105:570-577. [DOI: 10.1002/bjs.10732] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 09/12/2017] [Accepted: 09/20/2017] [Indexed: 01/30/2023]
Abstract
Abstract
Background
Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure.
Methods
Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis.
Results
One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure.
Conclusion
DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.
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Affiliation(s)
- C Cosse
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
- Institut National de la Santé et de la Recherche Médicale U1088, Jules Verne University of Picardie, Amiens, France
| | - L Rebibo
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - F Brazier
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - S Hakim
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - R Delcenserie
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - J M Regimbeau
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
- EA4294, Jules Verne University of Picardie, Amiens, France
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Lorenzo D, Guilbaud T, Gonzalez JM, Benezech A, Dutour A, Boullu S, Berdah S, Bège T, Barthet M. Endoscopic treatment of fistulas after sleeve gastrectomy: a comparison of internal drainage versus closure. Gastrointest Endosc 2018; 87:429-437. [PMID: 28750839 DOI: 10.1016/j.gie.2017.07.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 07/19/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Fistulas after sleeve gastrectomy are major adverse events of bariatric surgery. The endoscopic management strategy evolved from closure to internal drainage after 2013. The main objective of our study was to evaluate and compare these different approaches. METHODS This retrospective study included all patients treated for fistulas after sleeve gastrectomy in a referral center. Closure management was defined as initial treatment that used a covered metal stent and/or endoclips. Internal drainage management was defined as initial treatment by nasocystic drain and/or a double-pigtail stent. RESULTS A total of 100 patients (women N = 78, mean [± standard deviation {SD}] age 42 ± 12 years) were included between 2007 and 2015. The mean (± SD) delay between sleeve gastrectomy and the first endoscopy was 82 ± 125 days. The overall success of endoscopic treatment was 86% within 6 ± 27 months. Two patients died. The primary success of internal drainage and closure management occurred in 19 of 22 (86%) and 49 of 77 (63%) patients, respectively. Among patients in failure for closure management, 22 had secondary internal drainage (18 being successful). Success of initial management was significantly higher for internal drainage (P = .043). Factors associated with failure of closure management were in multivariable analysis: collection >5 cm (P = .013). Factors associated with a time >6 months for achieving leakage closure were in multivariable analysis: reoperation before endoscopy (P = .044) and purulent flow at endoscopy (P = .043). CONCLUSIONS Endoscopic management of fistulas after sleeve gastrectomy was successful in 86% of cases. In cases of collections >5 cm, internal drainage should be proposed first. Surgical reintervention before endoscopy delays treatment success.
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Affiliation(s)
- Diane Lorenzo
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Théophile Guilbaud
- Department of Visceral Surgery, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Jean Michel Gonzalez
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Alban Benezech
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Anne Dutour
- Department of Endocrinology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Sandrine Boullu
- Department of Endocrinology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Stéphane Berdah
- Department of Visceral Surgery, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Thierry Bège
- Department of Visceral Surgery, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
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Boerlage TCC, Houben GPM, Groenen MJM, van der Linde K, van de Laar AWJM, Emous M, Fockens P, Voermans RP. A novel fully covered double-bump stent for staple line leaks after bariatric surgery: a retrospective analysis. Surg Endosc 2018; 32:3174-3180. [PMID: 29344787 PMCID: PMC5988771 DOI: 10.1007/s00464-018-6034-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 01/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Staple line leakage after bariatric surgery can be treated by endoscopic placement of a self-expandable stent. The success rate of stent placement is generally high, but migration is a frequent adverse event that hampers successful treatment. The Niti-S Beta stent is a fully covered double-bump stent that was specifically designed to prevent migration. This study aimed to evaluate the effectiveness and adverse event rate of the Niti-S Beta stent. METHODS A retrospective study was performed in three high-volume bariatric centers. All consecutive patients between 2009 and 2016 who underwent placement of a Beta stent for staple line leakage were included. Primary outcome was resolution of the leakage; secondary outcome was the adverse event rate including migration. RESULTS Thirty-eight patients were included. Twenty-five (66%) had resolution of the leakage. Success rate was higher in patients who were treated with implantation of a Beta stent as initial treatment (100%) than in patients who were treated with a stent after revisional surgery had failed (55%, p = 0.013). Migration occurred in 12 patients (32%). There were two severe adverse events requiring surgical intervention, including a bleeding from an aorto-esophageal fistula. CONCLUSIONS The success rate and the migration rate of the Beta stent seem comparable to other stents in this retrospective study. Despite the novel double-bump structure of the stent, the migration rate does not seem to be decreased.
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Affiliation(s)
- Thomas C C Boerlage
- Department of Internal Medicine, MC Slotervaart, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands. .,Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Gerardus P M Houben
- Department of Gastroenterology & Hepatology, MC Slotervaart, Amsterdam, The Netherlands
| | - Marcel J M Groenen
- Department of Gastroenterology & Hepatology, Rijnstate ziekenhuis, Arnhem, The Netherlands
| | - Klaas van der Linde
- Department of Gastroenterology & Hepatology, MC Leeuwarden, Leeuwarden, The Netherlands
| | | | - Marloes Emous
- Department of Surgery, MC Leeuwarden, Leeuwarden, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Gastroenterology & Hepatology, MC Slotervaart, Amsterdam, The Netherlands
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Shehab H. Enteral stents in the management of post-bariatric surgery leaks. Surg Obes Relat Dis 2017; 14:393-403. [PMID: 29428690 DOI: 10.1016/j.soard.2017.12.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/10/2017] [Accepted: 12/13/2017] [Indexed: 02/07/2023]
Abstract
A post-bariatric surgery leak is a rare but grave condition and remains every bariatric surgeon's nightmare. Endoscopic therapy with the insertion of self-expandable stents provides an effective minimally invasive approach for the management of leaks. Self-expandable stents, however, are still hampered by their tendency for migration and are not always well tolerated. Recently, double-pigtail stents have been proposed as an alternative endoscopic therapeutic modality. Both types of stents have been shown to be very effective in the management of leaks; however, most studies have pooled gastrointestinal leaks due to different etiologies together. In this article, we review the current status and foreseen innovations in gastrointestinal stenting for post-bariatric surgery leaks.
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Affiliation(s)
- Hany Shehab
- Gastrointestinal Endoscopy unit, Department of Gastroenterology, Cairo University, Cairo, Egypt.
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Shehab H, Abdallah E, Gawdat K, Elattar I. Large Bariatric-Specific Stents and Over-the-Scope Clips in the Management of Post-Bariatric Surgery Leaks. Obes Surg 2017; 28:15-24. [DOI: 10.1007/s11695-017-2808-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Inversion Technique for the Removal of Partially Covered Self-Expandable Metallic Stents. Obes Surg 2017; 28:161-168. [DOI: 10.1007/s11695-017-2811-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Souto-Rodríguez R, Alvarez-Sánchez MV. Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results. World J Gastrointest Endosc 2017; 9:105-126. [PMID: 28360973 PMCID: PMC5355758 DOI: 10.4253/wjge.v9.i3.105] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/12/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.
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40
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Garofalo F, Noreau-Nguyen M, Denis R, Atlas H, Garneau P, Pescarus R. Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents. Surg Obes Relat Dis 2016; 13:925-932. [PMID: 28237561 DOI: 10.1016/j.soard.2016.12.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) has become a widely accepted option in the treatment of morbid obesity. Gastric leaks after SG occur in .9%-2.2% of the patients, mostly at the gastroesophageal junction. The current treatment algorithm includes drainage, antibiotics, nutritional support, and endoluminal control. OBJECTIVES Our hypothesis is that long, fully covered stents represent a safe, effective solution for SG leaks. SETTING University hospital. METHODS A retrospective analysis of our prospectively collected bariatric database was performed between June 2014 and May 2016. We included all patients treated for leaks after SG. Endoscopic treatment included partially covered metallic stent (Wallstent, Boston Scientific, Galway, Ireland), fully covered stent (Mega stent, Taewoong Medical Industries, Gyeonggi-do, South Korea), over-the-scope clip (Ovesco Endoscopy, Tubingen, Germany), and internal pigtail drainage. RESULTS A total of 872 SGs were performed. Overall, 10 of 872 patients (1.1%) developed a gastric leak. One patient was an outside referral. The 11 patients underwent endoscopic treatment accompanied by either percutaneous or laparoscopic abscess drainage. Endoscopic fistula closure at the gastroesophageal junction was achieved in 10 of 11 cases and the average time for closure was 9.9 (range: 4-24) weeks. One patient developed a second leak in the antrum, treated by subtotal gastrectomy. Overall, treatment with Wallstent failed in 3 of 5 patients, and these patients were eventually successfully treated with a Mega stent. The initial use of long, fully covered stents was successful in 5 of 6 cases. CONCLUSION Long, fully covered stents appear to be a good alternative to traditional stents either as primary treatment or after failure of other endoscopic treatments.
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Affiliation(s)
- Fabio Garofalo
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Maxime Noreau-Nguyen
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Ronald Denis
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Henri Atlas
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Pierre Garneau
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Radu Pescarus
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.
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Joo MK. Endoscopic Approach for Major Complications of Bariatric Surgery. Clin Endosc 2016; 50:31-41. [PMID: 28008162 PMCID: PMC5299989 DOI: 10.5946/ce.2016.140] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022] Open
Abstract
As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.
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Affiliation(s)
- Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul, Korea
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42
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Garofalo F, Atlas H, Pescarus R. Laparoscopic treatment of gastrocolic fistula: a rare complication post-sleeve gastrectomy. Surg Obes Relat Dis 2016; 12:1761-1763. [PMID: 27687909 DOI: 10.1016/j.soard.2016.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/13/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Fabio Garofalo
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada
| | - Henri Atlas
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada
| | - Radu Pescarus
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada.
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43
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Shehab H, Baron TH. Enteral stents in the management of gastrointestinal leaks, perforations and fistulae. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Hany Shehab
- Gastrointestinal Endoscopy Unit, Kasralainy University Hospital, Cairo University, Cairo, Egypt
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Athanasiou A, Spartalis E, Alexandrou A, Liakakos T. Comment on "Laparo-Endoscopic Gastrostomy (LEG) Decompression: a Novel One-time Method of Management of Gastric Leaks Following Sleeve Gastrectomy". Obes Surg 2015; 26:620-1. [PMID: 26694211 DOI: 10.1007/s11695-015-2015-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Antonios Athanasiou
- 1st Surgery Department, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece.
| | - Eleftherios Spartalis
- 1st Surgery Department, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece.
| | - Andreas Alexandrou
- 1st Surgery Department, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece.
| | - Theodoros Liakakos
- 1st Surgery Department, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece.
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