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

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.

Endoscopic therapeutic interventions for management of postoperative bariatric surgery complications

“…For early leaks percutaneous drains placed either by surgery or interventional radiology may be an option. However, in delayed leaks, endoscopic internal drainage is gaining traction especially in a well circumscribed fluid collection [22,23].…”

The Causes, Prevention, and Management of Gastric Leakage after Laparoscopic Sleeve Gastrectomy: A Review Article

“…Most authors have reported the use of this test, although the drain is sometimes removed before the fistula has been diagnosed. This diagnostic method can be useful only when the result is positive, since a negative finding does not exclude the possibility of a fistula [13,14].…”

“…An intraoperative photo showing the first stapler with a black cartridge applied around 5 cm from the pylorus.(Fig. 2)[14,16].STEPS FOR MINIMIZING THE OCCURRENCE OF POST-LSG LEAKAGEMany studies conclude that different techniques may play an important role in the possibility of decreasing post-LSG leakage. These techniques are as follows: use a bougie size of ≥40 Fr; begin the gastric transection 5-6 cm from the pylorus ; use suitable cartridge colors from the antrum to the fundus; reinforce the staple line with a buttress material; follow a proper staple line; remove the crotch staples; preserve proper traction on the stomach before firing; stay away from the Angle Of His by at least 1 cm; check the bleeding from the staple line; and perform…”

EUS-directed transgastric access to the excluded stomach to facilitate pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy

“…For many years, the standard techniques to endoscopically access the pancreaticobiliary region for diagnostic or therapeutic reasons have been enteroscopy-assisted ERCP (e-ERCP) and laparoscopy-assisted ERCP (l-ERCP). [45] The main limitations of e-ERCP include required proficiency at enteroscopy, long procedure time required to reach the ampulla, technical success of only 50%, and limited ERCP accessories that are appropriate for use with an enteroscope. [5] In addition, repeat e-ERCP is time-consuming as accessing the ampulla through deep enteroscopy remains challenging.…”