Endoscopic management of bariatric complications: A review and update

Abstract

With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.

Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS)

“…The median time between insertion of the first stent and retrieval of the final stent was 6.2 weeks (range 0. [4][5][6][7][8][9][10][11][12][13][14] with resolution of the leak occurring in 18 patients (90 %). Eight patients (40 %) required one endoscopic procedure where a stent was inserted to resolve the leak, 10 patients (50 %) needed two consecutive procedures with stents being placed, and two patients (10 %) required three successive procedures.…”

“…The benefits of SEMS include providing a barrier between intraluminal contents and the healing anastomosis to prevent leakage and subsequent infection while simultaneously allowing for oral nutrition. However, the management of leaks with endoscopic stents is not without problems, the most common being stent migration [9,14,17,24,25]. Other complications include tissue ingrowth, mucosal erosion, and endoscopic complications associated with placement and removal such as perforation.…”

“…All the stents were removed successfully, and clinical resolution was achieved in 18 patients (90 %) after a median of two (range 1-3) procedures and a mean of 6.2 weeks (range 0. [4][5][6][7][8][9][10][11][12][13][14]. Complications presented in 12 patients (60 %), including stent migration (n = 8), mucosal friability (n = 4), tissue integration (n = 2), and bleeding (n = 2).…”

“…While there have been improvements in clinical outcomes in recent years, anastomotic and stapleline leaks remain a potentially deadly complication of foregut surgery associated with significant morbidity and mortality and have been reported at rates up to 10 % of the time [5][6][7][8][9][10]. Leaks are thought to be the result of a variety of etiologies including stapler misfire, wrong staple size for the tissue, tissue trauma, or ischemia due to either tension on the anastomosis or a hematoma [9]. Although primary repair for leaks has been effective historically, it too is associated with significant morbidity and mortality [11][12][13].…”

“…With recent advancements in endoscopy, the use of fully covered self-expanding metal stents (SEMS) has been gaining popularity as a minimally invasive treatment of gastrointestinal leaks for both malignant [14][15][16][17] and benign [9,18,19] pathologies. Although SEMS were only FDA approved for malignant stricture, many endoscopists have been pushing the envelope in the past decade and using SEMS to treat anastomotic leaks after foregut surgery.…”