Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results

Figure 1 Bariatric surgery procedures. A: Adjustable gastric band; B: Roux-en-Y gastric bypass; C: Sleeve gastrectomy; D: Sleeve gastrectomy with biliopancreatic diversion.

Figure 2 Large collections requiring lavage to eliminate pus and debris. A: Early fluid collection after RYGB; B and C: Transfistulary drainage of the fluid collection. A 10 Fr double pigtail was placed; D: Nine days after stent placement the collection significantly reduced and became a virtual cavity. Yellow arrow: Double pigtail stent; white arrow: Reduced cavity after drainage. RYGB: Roux-en-Y gastric bypass.

Figure 3 Hanarostent^® (MI-tech, Seoul, South Korea). Fully-covered self-expandable stent adapted to the sleeve gastrectomy anatomy.

Figure 4 Over-the-scope clip (Ovesco Endoscopy, Tübingen, Germay). The over-the-scope clip attached to the gastroscope tip and ready to be placed on the wall defect. At the bottom of the figure, different available sizes of over-the-scope clip in the final position once they have been released.

Figure 5 Upper gastrointestinal series displaying a small gastrogastric fístula ten days after Roux-en-Y gastric bypass (arrows).

Figure 6 Leak resolution after stent deployement. A: The same gastrogastric fistula (arrow) as in Figure 5 confirmed by CT scan with oral water-soluble contrast. A fully covered self-expandable metal stent was inserted. The stent was removed after forty three days and a complimentary injection of fibrin glue was performed; B: A new CT scan revelaed the fistula closure. CT: Computed tomography.

Figure 7 Management algorithm for post-bariatric surgery leaks. Leaks have been classified based on the time period they appear as early, between first and fourth day post-operative, intermediate, between the fifth and ninth day after surgery, and late appearing after day ten. ^aSome authors prefer surgical repair in early small-volume leaks; ^bExcept in uncomplicated small early leaks where conservative treatment has 75% of success in leak closure and the potential benefits of SEES are shadowed by the risk of migration and related complications. SEMS: Self-expanding metal stent; OTSC: Over-the-scope clip.

Figure 8 Endoscopic retrograde cholangiopancreatography approaches in Roux-en-Y gastric bypass. A: Laparoscopic-assisted endoscopic retrograde cholangiopancreatography; B: Endoscopically-assisted endoscopic retrograde cholangiopancreatography.