Keep calm under pressure: a paradigm shift in managing postsurgical leaks

Vargas, Eric J.; Dayyeh, Barham K. Abu

doi:10.1016/j.gie.2017.09.016

Cited by 19 publications

(9 citation statements)

References 9 publications

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“…Therapeutic endoscopy plays a major role in management of UGI anastomotic leaks, offering an effective treatment alternative to repeat surgery 10 . The available endoscopic approaches range from primary to secondary closure techniques, with varying degrees of technical and clinical success and adverse events, generating a lack of consensus regarding the most appropriate endoscopic management 11 .…”

Section: Discussionmentioning

confidence: 99%

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks

Rodrigues‐Pinto

Repici

Donatelli³

et al. 2019

Endosc Int Open

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Background and study aims A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.

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Section: Discussionmentioning

confidence: 99%

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks

Rodrigues‐Pinto

Repici

Donatelli³

et al. 2019

Endosc Int Open

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“…Endoscopy plays a major role in the management of postbariatric leaks 7 . The available endoscopic approaches range from primary to secondary closure techniques, with varying degrees of technical and clinical success and adverse events, generating a lack of consensus regarding the most appropriate endoscopic management 4 . However, in recent years, management has been moving from bridging and closing the leak’s orifice (with stents, clips, tissue sealants, and sutures) toward an approach that uses vacuum therapy or internal drainage.…”

Section: Discussionmentioning

confidence: 99%

“…Leaks after RYGB can occur at multiple points along any staple line, including the gastric pouch, the gastrojejunal anastomosis (most common location), the blind portion of the Roux limb, the jejunojejunal anastomosis, and the remnant stomach 3 . Leaks after sleeve gastrectomy are typically found near the angle of His, wherein the staple-line meets the gastroesophageal junction 4 …”

Section: Introductionmentioning

confidence: 99%

Role of endoscopic vacuum therapy, internal drainage, and stents for postbariatric leaks

et al. 2019

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Background and AimsTherapeutic endoscopy plays a major role in the management of postbariatric anastomotic leaks, offering an effective treatment alternative to repeated surgery. In recent years, management has been moving from bridging and closing the leak’s orifice toward an approach that uses vacuum therapy or internal drainage. Our aim was to demonstrate different treatment options for the management of postbariatric leaks.MethodsWe describe 3 different endoscopic techniques for postbariatric leaks in 2 patients who had undergone Roux-en-Y gastric bypass (RYGB) and 1 patient who had undergone sleeve gastrectomy.ResultsThe first patient had a 20-mm early post-RYGB leak with an intra-abdominal associated collection treated with 5 sessions of endoscopic vacuum therapy (EVT). The second patient had a 12-mm acute postgastric sleeve leak with an associated collection, in whom therapy with EVT had failed, and who was then treated with endoscopic internal drainage (EID). The last patient had a chronic intra-abdominal collection after RYGB, despite reoperation, in whom therapy with EID and esophageal stent had failed, and who was treated with a diabolo-shaped lumen-apposing metal stent placed between the gastric pouch and the gastric remnant. Weight-loss intention was not compromised in any patient. All patients remain well.ConclusionsStaple-line or anastomotic leaks are an important cause of morbidity and mortality after surgery. There are myriad endoscopic techniques, with varying reported efficacy. Often, more than one endoscopic approach can be used concomitantly, whereas in other cases, therapies are applied sequentially depending on the initial clinical response. Multiple therapeutic options should be considered before endoscopic failure.

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“…She had recurrent sepsis 3 days later due to a perigastric abscess. An esophageal stent (23 mm × 15 cm) was deployed [1][2][3] and sutured to the wall. The abscess was aspirated percutaneously.…”

mentioning

confidence: 99%

“…The stent was removed and no patent orifice was identified. Pneumatic dilation of narrowing at the incisura angularis [1][2][3] was performed (30-mm balloon, PSI 15). Endoscopic ultrasound (EUS)-guided drainage using a double pigtail stent was performed (▶ Fig.…”

mentioning

confidence: 99%

EUS-guided drainage with LAMS to treat a refractory micro-fistula after sleeve gastrectomy: Widen the fistula if you cannot seal it

Lajin

2021

Endosc Int Open

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Keep calm under pressure: a paradigm shift in managing postsurgical leaks

Cited by 19 publications

References 9 publications

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks

Role of endoscopic vacuum therapy, internal drainage, and stents for postbariatric leaks

EUS-guided drainage with LAMS to treat a refractory micro-fistula after sleeve gastrectomy: Widen the fistula if you cannot seal it

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