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Surgical Endoscopy

, Volume 27, Issue 3, pp 808–816 | Cite as

Stent treatment for fistula after obesity surgery: results in 47 consecutive patients

  • Haicam El Mourad
  • Jacques Himpens
  • Johan Verhofstadt
Article

Abstract

Background

Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery.

Methods

We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications.

Results

There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment.

Conclusions

Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.

Keywords

Laparoscopic obesity surgery Leaks Stent treatment 

Notes

Disclosures

Drs. Haicam El Mourad and Johan Verhofstadt have no conflicts of interest or financial ties to disclose. Dr. J Himpens is a consultant with Ethicon Endosurgery and gives talks and organizes workshops for Gore, but there is no conflict of interest with the material presented in this article.

References

  1. 1.
    Fuks D, Verhaeghe P, Brehant O, Sabbagh C, Dumont F, Riboulot M, Delcenserie R, Regimbeau JM (2009) Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery 145(1):106–113PubMedCrossRefGoogle Scholar
  2. 2.
    Spyropoulos C, Kehagias I, Panagiotopoulos S, Mead N, Kalfarentzos F (2010) Revisional bariatric surgery: 13-year experience from a tertiary institution. Arch Surg 145(2):173–177PubMedCrossRefGoogle Scholar
  3. 3.
    Hallowell PT, Stellato TA, Yao DA, Robinson A, Schuster MM, Graf KN (2009) Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Am J Surg 197(3):391–396PubMedCrossRefGoogle Scholar
  4. 4.
    Shchepotin IB, Evans SR, Chorny VA, Shabahang M, Buras RR, Nauta RJ (1996) Postoperative complications requiring relaparotomies after 700 gastrectomies performed for gastric cancer. Am J Surg 171(2):270–273PubMedCrossRefGoogle Scholar
  5. 5.
    Csendes A, Braghetto I, León P, Burgos AM (2010) Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg 14(19):1343–1348PubMedCrossRefGoogle Scholar
  6. 6.
    Zonca P, Cambal M, Jacobi CA (2010) Complicated course after sleeve gastrectomy for obesity. Bratisl Lek Listy 111(4):231–234PubMedGoogle Scholar
  7. 7.
    Madan AK, Lanier B, Tichansky DS (2006) Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass. Am Surg 72(7):586–590PubMedGoogle Scholar
  8. 8.
    Thurairajah P, Hawthorne AB (2004) Endoscopic clipping of a nonhealing gastrocutaneous fistula following gastrostomy removal. Endoscopy 36(9):834PubMedCrossRefGoogle Scholar
  9. 9.
    Ramón Rábago L, Moral I, Delgado M, Guerra I, Quintanilla E, Castro JL, Llorente R, Martínez Veiga JL, Gea F (2006) Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue. Gastroenterol Hepatol 29(7):390–396PubMedCrossRefGoogle Scholar
  10. 10.
    Papavramidis ST, Eleftheriadis EE, Papavramidis TS, Kotzampassi KE, Gamvros OG (2004) Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant. Gastrointest Endosc 23(12):1802–1805Google Scholar
  11. 11.
    Toussaint E, Eisendrath P, Kwan V, Dugardeyn S, Devière J, Le Moine O (2009) Endoscopic treatment of postoperative enterocutaneous fistulas after bariatric surgery with the use of a fistula plug: report of five cases. Endoscopy 41(6):560–563PubMedCrossRefGoogle Scholar
  12. 12.
    Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ (2010) Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg 89(3):931–937PubMedCrossRefGoogle Scholar
  13. 13.
    Casella G, Soricelli E, Rizzello M, Trentino P, Fiocca F, Fantini A, Salvatori FM, Basso N (2009) Non surgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 19(7):821–826PubMedCrossRefGoogle Scholar
  14. 14.
    Merrifield BF, Lautz D, Thompson CC (2006) Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach. Gastrointest Endosc 63(4):710–714PubMedCrossRefGoogle Scholar
  15. 15.
    Ballesta C, Berindoague R, Cabrera M, Palau M, Gonzales M (2008) Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg 18(6):623–630PubMedCrossRefGoogle Scholar
  16. 16.
    Burgos AM, Braghetto I, Csendes A, Maluenda F, Korn O, Yarmuch J, Gutierrez L (2009) Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg 19(12):1672–1677PubMedCrossRefGoogle Scholar
  17. 17.
    Durak E, Inabnet WB, Schrope B, Davis D, Daud A, Milone L, Bessler M (2008) Incidence and management of enteric leaks after gastric bypass for morbid obesity during a 10-year period. Surg Obes Relat Dis 4(3):389–393PubMedCrossRefGoogle Scholar
  18. 18.
    Kim W, Song KY, Lee HJ, Han SU, Hyung WJ, Cho GS (2008) The impact of comorbidity on surgical outcomes in laparoscopy-assisted distal gastrectomy: a retrospective analysis of multicenter results. Ann Surg 248(5):793–799PubMedCrossRefGoogle Scholar
  19. 19.
    Kunisaki C, Makino H, Takagawa R, Sato K, Kawamata M, Kanazawa A, Yamamoto N, Nagano Y, Fujii S, Ono HA, Akiyama H, Shimada H (2009) Predictive factors for surgical complications of laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Endosc 23(9):2085–2093PubMedCrossRefGoogle Scholar
  20. 20.
    Menenakos E, Stamou KM, Albanopoulos K, Papailiou J, Theodorou D, Leandros E (2010) Laparoscopic sleeve gastrectomy performed with intent to treat morbid obesity: a prospective single-center study of 261 patients with a median follow-up of 1 year. Obes Surg 20(23):276–282PubMedCrossRefGoogle Scholar
  21. 21.
    Sánchez-Santos R, Masdevall C, Baltasar A, Martínez-Blázquez C, Ruiz García, de Gordejuela A, Ponsi E, Sánchez-Pernaute A, Vesperinas G, Del Castillo D, Bombuy E, Durán-Escribano C, Ortega L, Ruiz de Adana JC, Baltar J, Maruri I, García-Blázquez E, Torres A (2009) Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry. Obes Surg 19(9):1203–1210PubMedCrossRefGoogle Scholar
  22. 22.
    Kellogg TA, Swan T, Leslie DA, Buchwald H, Ikramuddin S (2009) Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass. Surg Obes Relat Dis 5(4):416–423PubMedCrossRefGoogle Scholar
  23. 23.
    Lambert DM, Marceau S, Forse RA (2005) Intra-abdominal pressure in the morbidly obese. Obes Surg 15(9):1225–1232PubMedCrossRefGoogle Scholar
  24. 24.
    Serra C, Baltasar A, Andreo L, Pérez N, Bou R, Bengochea M, Chisbert JJ (2007) Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy. Obes Surg 17(7):866–872PubMedCrossRefGoogle Scholar
  25. 25.
    Papavramidis TS, Kotzampassi K, Kotidis E, Eleftheriadis EE, Papavramidis ST (2008) Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch. J Gastroenterol Hepatol 23(12):1802–1805PubMedCrossRefGoogle Scholar
  26. 26.
    Eisendrath P, Cremer M, Himpens J, Cadière GB, Le Moine O, Devière J (2007) Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy 39(7):625–630PubMedCrossRefGoogle Scholar
  27. 27.
    Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M (2004) Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 99(10):2051–2957PubMedCrossRefGoogle Scholar
  28. 28.
    Siddiqui AA, Ansari S, Ghouri MA, Memon MS (2010) Self expandable metallic stent endoscopic insertion in esophageal cancer. J Coll Physicians Surg Park 20(8):502–505Google Scholar
  29. 29.
    Dobrucali A, Caglar E (2010) Palliation of malignant esophageal obstruction and fistulas with self expandable metallic stents. World J Gastroenterol 16(45):5739–5745PubMedCrossRefGoogle Scholar
  30. 30.
    Robson PC, Heffernan N, Gonen M, Thornton R, Brody LA, Holmes R, Brown KT, Covey AM, Fleischer D, Getrajdman GI, Jarnagin W, Sofocleous C, Blumgart L, D Angelica M (2010) Prospective study of outcomes after percutaneous biliary drainage for malignant biliary obstruction. Ann Surg Oncol 17(19):2303–2311PubMedCrossRefGoogle Scholar
  31. 31.
    Yang RM, Han XW, Wu G, Li YD, Li FB (2007) Implantation of a self-expandable metallic inverted Y-stent to treat tracheobronchial stenosis in the carinal region: initial clinical experience. Clin Radiol 62(12):1223–1228PubMedCrossRefGoogle Scholar
  32. 32.
    Park do H, Kim MH, Moon SH, Lee SS, Seo DW, Lee SK (2008) Feasibility and safety of placement of a newly designed, fully covered self-expandable metal stent for refractory benign pancreatic ductal strictures: a pilot study [with video]. Gastrointest Endosc 68(6):1182–1189PubMedCrossRefGoogle Scholar
  33. 33.
    Taheri MR, Singh H, Duerksen DR (2011) Peritonitis after gastrostomy tube replacement: a case series and review of literature. J Parenter Enteral Nutr 35(1):56–60CrossRefGoogle Scholar
  34. 34.
    Rolleston HD, Oliver MW (1909) Secondary parotitis due to oral starvation in the medical treatment of gastric ulcer. Br Med J 1(2526):1296–1297PubMedCrossRefGoogle Scholar
  35. 35.
    Mazaki T, Ebisawa K (2008) Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg 12(4):739–755PubMedCrossRefGoogle Scholar
  36. 36.
    Raman M, Gramlich L, Whittaker S, Allard JP (2007) Canadian home total parenteral nutrition registry: preliminary data on the patient population. Can J Gastroenterol 21(10):643–648PubMedGoogle Scholar
  37. 37.
    Swinnen J, Eisendrath P, Rigaux J, Kahegeshe L, Lemmers A, Le Moine O, Devière J (2011) Self-expandable metal stents for the treatment of benign upper GI leaks and perforations. Gastrointest Endosc 73(5):890–899PubMedCrossRefGoogle Scholar
  38. 38.
    De Palma GD, di Matteo E, Romano G, Fimmano A, Rondinone G, Catanzano C (1996) Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 43(5):478–482PubMedCrossRefGoogle Scholar
  39. 39.
    Eubanks S, Edwards CA, Fearing NM, Ramaswamy A, de la Torre RA, Thaler KJ, Miedema BW, Scott JS (2008) Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg 206(5):935–938PubMedCrossRefGoogle Scholar
  40. 40.
    Hirdes MM, Vleggaar FP, Van der Linde K, Willems M, Totté ER, Siersema PD (2010) Esophageal perforation due to removal of partially covered self-expanding metal stents placed for a benign perforation or leak. Endoscopy 43(2):156–159PubMedCrossRefGoogle Scholar
  41. 41.
    Tunçözgür B, Savaş MC, Işik AF, Sarimehmetoğlu A, Sanli M, Elbeyli L (2006) Removal of metallic stent by using polyflex stent in esophago-colic anastomotic stricture. Ann Thorac Surg 82(5):1913–1914PubMedCrossRefGoogle Scholar
  42. 42.
    Baltasar A, Bou R, Bengochea M, Serra C, Cipagauta L (2009) Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy. Obes Surg 17(10):1408–1410CrossRefGoogle Scholar
  43. 43.
    Fuks D, Dumont F, Berna P, Verhaeghe P, Sinna R, Sabbagh C, Demuynck F, Yzet T, Delcenserie R, Bartoli E, Regimbeau JM (2009) Case report–complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy. Obes Surg 19(12):261–264PubMedCrossRefGoogle Scholar
  44. 44.
    Pettit SH, Irving MH (1988) The operative management of fistulous Crohn’s disease. Surg Gynecol Obstet 167(3):223–228PubMedGoogle Scholar
  45. 45.
    Serra C, Baltasar A, Pérez N, Bou R, Bengochea M (2006) Total gastrectomy for complications of the duodenal switch, with reversal. Obes Surg 16(18):1082–1086PubMedCrossRefGoogle Scholar
  46. 46.
    Martin TD, Feliciano DV, Mattox KL, Jordan GL Jr (1983) Severe duodenal injuries. Treatment with pyloric exclusion and gastrojejunostomy. Arch Surg 118(5):631–635PubMedCrossRefGoogle Scholar
  47. 47.
    Honkoop P, Siersema PD, Tilanus HW, Stassen LP, Hop WC, van Blankenstein M (1996) Benign anastomotic strictures after transhiatal esophagectomy: risk factors and management. J Thorac Cardiovasc Surg 111(6):1141–1146PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Haicam El Mourad
    • 1
  • Jacques Himpens
    • 1
  • Johan Verhofstadt
    • 2
  1. 1.Obesity Surgery DepartmentAZ St. Blasius HospitalDendermondeBelgium
  2. 2.Gastro-enterology DepartmentAZ St. Blasius HospitalDendermondeBelgium

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