Septotomy and Balloon Dilation to Treat Chronic Leak After Sleeve Gastrectomy: Technical Principles

Abstract

Septotomy and balloon dilation were initially performed on a difficult-to-treat chronic fistula after gastric bypass and named before as stricturotomy (Campos JM, Siqueira LT, Ferraz AA, et al., J Am Coll Surg 204(4):711, 2007). This procedure allows internal drainage of the fistula and deviates oral intake to the pouch. In addition, achalasia balloon dilation treats strictures and axis deviation of the gastric chamber, promoting reduction of the intragastric pressure. Septotomy and balloon dilation are technically feasible and might be useful in selected cases for closure of chronic leaks after LSG.

Utility of the balloon-overtube-assisted modified over-thewire stenting technique to treat post-sleeve gastrectomy complications

“…Management mainly depends on the timing and clinical presentation of the leak, being a new surgical approach indicated in septic or hemodynamically unstable patients[1,6-9]. After controlling the septic state, efforts must be focused on healing the gastric leak and various endoscopic techniques have been successfully applied, namely endoclips, fibrin glue, over-the-scope clips, septotomy combined with balloon dilation and covered stents[2,4,6,8,10-13]. Covered stents are a novel treatment approach for leaks after bariatric surgery, being minimally invasive, relatively safe and successful in 88% of cases[4,7,9].…”

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

“…To drain the leaked content, stricturotomy, more recently named as septotomy, has been successfully tried in patients with postoperative leaks after SG or DS[92,93]. This procedure derives from the endoscopic treatment for Zencker diverticulum and involves cutting the septum between the perigastric cavity and the gastric pouch using argon plasma coagulation or a needle-knife.…”

“…Therefore, in combination with achalasia balloon dilation of post-LSG stenosis, septotomy has become an appealing alternative to treat chronic leaks connected to a not drained cavity after LSG. This procedure allows decreasing intragastric pressure, rerouting the gastric content and the internal drainage of the cavity by cutting the staple-line interposed between the cavity and the gastric lumen[92,93]. Anecdotal experience with internal drainage using a vacuum-assisted closure system is now available[94,95].…”

“…However, the results of endoluminal therapy, including SEMS, in chronic leaks after bariatric surgery are far from optimal[51]. Recently, promising results with the septotomy procedure in the management of chronic leaks connected to a not drained cavity have led some experts to favor this technique against SEMS[92,93]. Yet, endoscopic treatment in the field of post-bariatric leaks has not been standardized and there is no consensus about the optimal timing and combination of endoscopic procedures.…”

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

“…The available endoscopic approaches for PSGL range from primary and secondary closure techniques with the use of endoluminal suturing devices, over-the-scope clips, fibrin glue, and diversion with self-expanding covered or partially covered metal stents, to EID techniques with the use of nasocystic drains or double-pigtail stents, 6 endoscopic vacuum therapy, 7 and septotomy with or without pneumatic dilation of the distal sleeve obstruction. 8 All the aforementioned techniques have reported varying degrees of both technical and clinical success and adverse events, generating a lack of consensus compounded by the scantiness of randomized Because not all leaks are created equal and available technical skills vary, we are left with devising a logical management algorithm based on comparative effectiveness and retrospective data but grounded in sound physiologic principles of wound healing and cost effectiveness, because some of the endoscopic management strategies are very costly and taxing on patients' time and quality of life.…”