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Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery

  • 2023 SAGES Oral
  • Published:
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Abstract

Introduction

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks.

Methods

A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed.

Results

The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43 years and a median follow-up of 24 months. The mean preoperative body mass index was 45.1 kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6 weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45 days after the index surgery.

Conclusions

Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6 weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

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References

  1. McKenna D, Selzer D, Burchett M, Choi J, Mattar SG (2014) Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss. Surg Obes Relat Dis Off J Am Soc Bariatr Surg 10(4):654–659

    Article  Google Scholar 

  2. Yan J, Cohen R, Aminian A (2017) Reoperative bariatric surgery for treatment of type 2 diabetes mellitus. Surg Obes Relat Dis Off J Am Soc Bariatr Surg 13(8):1412–1421

    Article  Google Scholar 

  3. Aleassa EM, Hassan M, Hayes K, Brethauer SA, Schauer PR, Aminian A (2019) Effect of revisional bariatric surgery on type 2 diabetes mellitus. Surg Endosc 33(8):2642–2648

    Article  PubMed  Google Scholar 

  4. Sjöström L, Gummesson A, Sjöström CD, Narbro K, Peltonen M, Wedel H et al (2009) Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol 10(7):653–662

    Article  PubMed  Google Scholar 

  5. Anveden Å, Taube M, Peltonen M, Jacobson P, Andersson-Assarsson JC, Sjöholm K et al (2017) Long-term incidence of female-specific cancer after bariatric surgery or usual care in the Swedish Obese Subjects Study. Gynecol Oncol 145(2):224–229

    Article  PubMed Central  Google Scholar 

  6. Schauer DP, Feigelson HS, Koebnick C, Caan B, Weinmann S, Leonard AC et al (2019) Bariatric surgery and the risk of cancer in a large multisite cohort. Ann Surg 269(1):95–101

    Article  PubMed  Google Scholar 

  7. Tao W, Santoni G, von Euler-Chelpin M, Ljung R, Lynge E, Pukkala E et al (2020) Cancer risk after bariatric surgery in a cohort study from the five Nordic countries. Obes Surg 30(10):3761–3767

    Article  PubMed  PubMed Central  Google Scholar 

  8. Aminian A, Wilson R, Al-Kurd A, Tu C, Milinovich A, Kroh M et al (2022) Association of bariatric surgery with cancer risk and mortality in adults with obesity. JAMA 327(24):2423–2433

    Article  PubMed  PubMed Central  Google Scholar 

  9. Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD et al (2007) Long-term mortality after gastric bypass surgery. N Engl J Med 357(8):753–761

    Article  CAS  PubMed  Google Scholar 

  10. Syn NL, Cummings DE, Wang LZ, Lin DJ, Zhao JJ, Loh M et al (2021) Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants. Lancet Lond Engl 397(10287):1830–1841

    Article  Google Scholar 

  11. Regan JP, Inabnet WB, Gagner M, Pomp A (2003) Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 13(6):861–864

    Article  CAS  PubMed  Google Scholar 

  12. Clapp B, Ponce J, DeMaria E, Ghanem O, Hutter M, Kothari S et al (2022) American Society for Metabolic and Bariatric Surgery 2020 estimate of metabolic and bariatric procedures performed in the United States. Surg Obes Relat Dis 18:1134–1140

  13. Aurora AR, Khaitan L, Saber AA (2012) Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 26(6):1509–1515

    Article  PubMed  Google Scholar 

  14. Rosenthal RJ (2012) International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 8(1):8–19

    Article  PubMed  Google Scholar 

  15. Rodrigues-Pinto E, Repici A, Donatelli G, Macedo G, Devière J, van Hooft JE et al (2019) International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks. Endosc Int Open 7(12):E1671–E1682

    Article  PubMed  PubMed Central  Google Scholar 

  16. Raju GS, Thompson C, Zwischenberger JB (2005) Emerging endoscopic options in the management of esophageal leaks (videos). Gastrointest Endosc 62(2):278–286

    Article  PubMed  Google Scholar 

  17. Gelbmann CM, Ratiu NL, Rath HC, Rogler G, Lock G, Schölmerich J et al (2004) Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy 36(8):695–699

    Article  CAS  PubMed  Google Scholar 

  18. Langer FB, Wenzl E, Prager G, Salat A, Miholic J, Mang T et al (2005) Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 79(2):398–403 (discussion 404)

    Article  PubMed  Google Scholar 

  19. Basha J, Appasani S, Sinha SK, Siddappa P, Dhaliwal HS, Verma GR et al (2014) Mega stents: a new option for management of leaks following laparoscopic sleeve gastrectomy. Endoscopy 46(Suppl 1):E49–E50

    PubMed  Google Scholar 

  20. Galloro G, Magno L, Musella M, Manta R, Zullo A, Forestieri P (2014) A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series. Surg Obes Relat Dis Off J Am Soc Bariatr Surg 10(4):607–611

    Article  Google Scholar 

  21. Garofalo F, Noreau-Nguyen M, Denis R, Atlas H, Garneau P, Pescarus R (2017) Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents. Surg Obes Relat Dis Off J Am Soc Bariatr Surg 13(6):925–932

    Article  Google Scholar 

  22. Shehab H, Abdallah E, Gawdat K, Elattar I (2018) Large bariatric-specific stents and over-the-scope clips in the management of post-bariatric surgery leaks. Obes Surg 28(1):15–24

    Article  PubMed  Google Scholar 

  23. Donatelli G, Ferretti S, Vergeau BM, Dhumane P, Dumont JL, Derhy S et al (2014) Endoscopic internal drainage with enteral nutrition (EDEN) for treatment of leaks following sleeve gastrectomy. Obes Surg 24(8):1400–1407

    Article  PubMed  Google Scholar 

  24. Loske G, Schorsch T, Müller C (2011) Intraluminal and intracavitary vacuum therapy for esophageal leakage: a new endoscopic minimally invasive approach. Endoscopy 43(6):540–544

    Article  CAS  PubMed  Google Scholar 

  25. Campos JM, Ferreira FC, Teixeira AF, Lima JS, Moon RC, D’Assunção MA et al (2016) Septotomy and balloon dilation to treat chronic leak after sleeve gastrectomy: technical principles. Obes Surg 26(8):1992–1993

    Article  PubMed  Google Scholar 

  26. Rodrigues-Pinto E, Pereira P, Sousa-Pinto B, Shehab H, Pinho R, Larsen MC et al (2021) Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks. Gastrointest Endosc 93(6):1283-1299.e2

    Article  PubMed  Google Scholar 

  27. Johari Y, Catchlove W, Tse M, Shaw K, Paul E, Chen R et al (2022) A 4-tier protocolized radiological classification system for leaks following sleeve gastrectomy. Ann Surg 275(2):e401

    Article  PubMed  Google Scholar 

  28. Park JY (2022) Diagnosis and management of postoperative complications after sleeve gastrectomy. J Metab Bariatr Surg 11(1):1–12

    Article  PubMed  PubMed Central  Google Scholar 

  29. Lainas P, Triantafyllou E, Ben Amor V, Savvala N, Gugenheim J, Dagher I et al (2022) Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy. Surg Obes Relat Dis Off J Am Soc Bariatr Surg S1550–7289(22):00806–00811

    Google Scholar 

  30. Rogalski P, Swidnicka-Siergiejko A, Wasielica-Berger J, Zienkiewicz D, Wieckowska B, Wroblewski E et al (2021) Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis. Surg Endosc 35(3):1067–1087

    Article  PubMed  Google Scholar 

  31. Manos T, Nedelcu M, Nedelcu A, Gagner M, Weiss AK, Bastid C et al (2021) Leak after sleeve gastrectomy: updated algorithm of treatment. Obes Surg 31(11):4861–4867

    Article  PubMed  Google Scholar 

  32. Christophorou D, Valats JC, Funakoshi N, Duflos C, Picot MC, Vedrenne B et al (2015) Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study. Endoscopy 47(11):988–996

    Article  PubMed  Google Scholar 

  33. Abou Rached A, Basile M, El Masri H (2014) Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol WJG 20(38):13904–13910

    Article  PubMed  Google Scholar 

  34. Sharples AJ, Mahawar K (2020) Systematic review and meta-analysis of randomised controlled trials comparing long-term outcomes of Roux-En-Y gastric bypass and sleeve gastrectomy. Obes Surg 30(2):664–672

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Hôpital du Sacré Coeur, Montreal, Canada

    Alexis Deffain, Heba Alfaris, Roy Hajjar, Felix Thibeault, Wael Dimassi, Ronald Denis, Pierre Y. Garneau, Anne-Sophie Studer & Radu Pescarus

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  1. Alexis Deffain
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  2. Heba Alfaris
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Correspondence to Alexis Deffain.

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Alexis Deffain, Heba Alfaris, Roy Hajjar, Felix Thibeault, Wael Dimassi, Ronald Denis, Pierre Y. Garneau, Anne-Sophie Studer and Radu Pescarus have no conflicts of interest or financial ties to disclose.

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Deffain, A., Alfaris, H., Hajjar, R. et al. Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery. Surg Endosc 37, 9358–9365 (2023). https://doi.org/10.1007/s00464-023-10386-2

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