Long-term outcome after endoscopic stent therapy for complications after bariatric surgery

Abstract

Although bariatric surgery effectively reduces the mortality risk from obesity-related comorbidities [1,2], it is associated with a 1-5% risk of anastomotic complications. Anastomotic leaks have traditionally been treated with a combination of drainage with long-term parenteral nutrition or postanastomotic enteral nutrition, allowing the leak to heal. Strictures at the gastrojejunostomy are initially treated with repeated endoscopic dilation, but revisional bariatric surgery is needed for refractory strictures with its associated high complication rate. Chronic fistulas are initially treated conservatively but often need high-risk revisional surgery. Recently, endoscopic covered stents have been used successfully for treatment of anastomotic complications after esophageal resection [3][4][5]. Case series evaluating stents to treat anastomotic leaks after Roux-en-Y gastric bypass have shown success [6][7][8][9]. However, the numbers of patients enrolled in these studies are small, and only short-term outcomes are reported.The primary aim of this study is to present long-term healing rates after endoscopically placed covered stents in the treatment of various anastomotic complications after bariatric surgery. The secondary aim is to analyze symptom improvement scores, complications, and factors affecting stent migration. Materials and methodsWe performed a retrospective analysis of all patients treated with endoscopic stents for staple-line complications after bariatric surgery from The study was approved by the University of Missouri Institutional Review Board.Inclusion criteria were patients who underwent either Roux-en-Y gastric bypass or sleeve gastrectomy with subsequent anastomotic complications defined as acute staple-line leaks, chronic anastomotic fistulas or refractory anastomotic strictures. Acute leaks were defined as those occurring within 1 month postoperatively. Refractory anastomotic strictures were defined as persistent clinically significant strictures that were endoscopically dilated more than twice without resolution. Chronic fistulas were defined as enterocutaneous or gastrogastric fistulas for longer than 1 month.The stents were placed using both endoscopic and fluoroscopic guidance with endoscopy being used to delineate the area of leak, stricture or fistula. This pathology was then marked with either a radiopaque marker on the skin surface or by injecting water-soluble contrast in the mucosa adjacent to the pathology to use as an internal marker. Strictures were identified and dilated for at least

A novel fully covered double-bump stent for staple line leaks after bariatric surgery: a retrospective analysis

“…Despite the novel double-bump structure of the Beta stent, which has specifically been designed to prevent migration, migration occurred in 32% of patients (26% of stents) in this study. This seems comparable to the results of other fully covered stents, with a migration rate of 18–67% in previous studies [8, 11, 16, 17, 19, 20]. Partially covered stents are less prone to migration with a migration rate of 5–15% [7, 10, 14, 15, 18].…”

ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management

“…Mainstays of laparoscopic or open re-exploration follow the principles of drainage, creation of a controlled fistula with drains, antimicrobial therapy, parenteral nutrition or enteral nutrition with consideration of feeding access of the jejunum either with a nasoenteric catheter placed beyond the area of leak or gastrostomy-tube placement in the gastric remnant Limited data are available in the form of case reports and small case series of the use of biologic tissue sealants as well as the use of endoscopic stent placement for a gastrojejunal leak [50][51][52]. Further research may be helpful in refining the application of these technologies,.…”

Endoscopic placement of fully covered self expanding metal stents for management of post-operative foregut leaks

“…opined that earlier stenting might further decrease mortality and morbidity of post-operative leaks in the future. [8] Various studies have demonstrated healing rates for oesophageal/post-operative leaks in the range of 94%[1920] - 32 %. [21] Even in long-standing perforations, those who would otherwise undergo oesophageal resection can still be good candidates for stent treatment.…”

“…[12] The main morbidity of covered stents is thought to be migration while that for uncovered stents was tissue in-growth and difficult extraction. [20] Covered metal stents can be removed safely in most patients with a low complication rate and are available with a larger diameter than silastic stents, allowing a water-tight bypass of the leak site. [25] In a small series of 6 patients using SEPS for anastomotic leaks arising from Roux-En-Y gastric bypass, Edwards et al .…”

“…[17] Iqbal et al . [20] pointed out that the migration rate was significantly lower for nitinol stents, overlapping stents, polyester stents >15 cm, nitinol stents >12 cm. Many authors have suggested various solutions for reducing the rates of migration-like increasing the number of anti-migration struts,[27] deployment of 2 stents with a greater than 3 cm overlap,[18] a modification of the stent by leaving the upper flare uncoated and with 2 polypropylene (Prolene ® ) threads brought out and fixed to prevent migration.…”