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Obesity Surgery

, Volume 19, Issue 8, pp 1163–1169 | Cite as

Lessons Learned Establishing an Animal Model for Endoscopic Stent Placement to Treat Gastrojejunal Anastomotic Leaks After Gastric Bypass

  • Emanuel Sporn
  • Brent W. Miedema
  • J. Andres Astudillo
  • Klaus ThalerEmail author
Research Article

Abstract

Background

Anastomotic leaks after Roux-en-Y gastric bypass (RYGB) cause significant morbidity and mortality. Placement of enteral stents may be an improvement to the current treatment, which is withholding of oral intake and total parenteral nutrition.

Methods

We established an open RYGB porcine model with a leak at the gastrojejunostomy in three pigs. A pilot study was then performed in five pigs, where Polyflex stents were placed across the leaking anastomosis and fixed with transmural sutures to the Roux limb. After 2 weeks, endoscopy, fluoroscopy, and necropsy were performed.

Results

One pig without stent died on the second postoperative day (POD) due to a volvulus unrelated to the leak. In the other two pigs, leaks with large abscesses were found at necropsy. Stents were placed in five pigs but required open surgical manipulation of the delivery system. One pig died on POD 3 due to a perforation in the posterior gastric wall likely caused by the rigid delivery system. One pig died from gastrojejunostomy leakage on POD 5. The leaks were healed in the remaining three pigs after 2 weeks. In one pig, a perforation of the jejunum 4 cm distal to the anastomosis was found. Stent migration to some extent was seen in all pigs.

Conclusion

Stent placement and fixation were feasible but had a high complication rate for treatment of a leaking gastrojejunal anastomosis in the open porcine model. The stent may have contributed to healing the leak in some pigs. Further studies should focus on improving stent delivery, sealing of the leak, and prevention of stent migration.

Keywords

Gastric bypass Leak Stent Gastrojejunostomy Complication Endoluminal 

Notes

Acknowledgement

We would like to thank Boston Scientific Inc. for funding this study, Ethicon Endosurgery Inc. for providing staplers, Olympus Inc. for providing endoscopic equipment, and Kris Toft for her help and assistance in the animal laboratory.

Disclosure

This study was funded by Boston Scientific Inc. Material support was provided by Boston Scientific Inc., Ethicon Endosurgery Inc. and Olympus Inc.

References

  1. 1.
    Almahmeed T, Gonzalez R, Nelson LG, Haines K, Gallagher SF, Murr MM. Morbidity of anastomotic leaks in patients undergoing Roux-en-Y gastric bypass. Arch Surg. 2007;142:954–7.CrossRefGoogle Scholar
  2. 2.
    Marshall JS, Srivastava A, Gupta SK, Rossi TR, DeBord JR. Roux-en-Y gastric bypass leak complications. Arch Surg. 2003;138:520–3; discussion 523–4.CrossRefGoogle Scholar
  3. 3.
    Rosenthal RJ, Szomstein S, Kennedy CI, Soto FC, Zundel N. Laparoscopic surgery for morbid obesity: 1,001 consecutive bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. Obes Surg. 2006;16:119–24.CrossRefGoogle Scholar
  4. 4.
    Gonzalez R, Nelson LG, Gallagher SF, Murr MM. Anastomotic leaks after laparoscopic gastric bypass. Obes Surg. 2004;14:1299–307.CrossRefGoogle Scholar
  5. 5.
    Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515–29.CrossRefGoogle Scholar
  6. 6.
    Fernandez AZ Jr, DeMaria EJ, Tichansky DS, Kellum JM, Wolfe LG, Meador J, et al. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc. 2004;18:193–7.CrossRefGoogle Scholar
  7. 7.
    Arteaga JR, Huerta S, Livingston EH. Management of gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass. Am Surgeon. 2002;68:1061–5.PubMedGoogle Scholar
  8. 8.
    Hunerbein M, Stroszczynski C, Moesta KT, Schlag PM. Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents. Ann Surg. 2004;240:801–7.CrossRefGoogle Scholar
  9. 9.
    Langer FB, Wenzl E, Prager G, Salat A, Miholic J, Mang T, Zacherl J. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg. 2005;79:398–403; discussion 404.CrossRefGoogle Scholar
  10. 10.
    Schubert D, Scheidbach H, Kuhn R, Wex C, Weiss G, Eder F, et al. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents. Gastrointest Endosc. 2005;61:891–6.CrossRefGoogle Scholar
  11. 11.
    Merrifield BF, Lautz D, Thompson CC. Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach. Gastrointest Endosc. 2006;63:710–4.CrossRefGoogle Scholar
  12. 12.
    Kriwanek S, Ott N, Ali-Abdullah S, Pulgram T, Tscherney R, Reiter M, et al. Treatment of gastro-jejunal leakage and fistulization after gastric bypass with coated self-expanding stents. Obes Surg. 2006;16:1669–74.CrossRefGoogle Scholar
  13. 13.
    Eubanks S, Edwards CA, Fearing NM, Ramaswamy A, de la Torre RA, Thaler KJ, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg 2008;206:935–938; discussion 938–939.CrossRefGoogle Scholar
  14. 14.
    Fukumoto R, Orlina J, McGinty J, Teixeira J. Use of Polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery. Surg Obes Relat Dis. 2007;3:68–71; discussion 71–62.CrossRefGoogle Scholar
  15. 15.
    Salinas A, Baptista A, Santiago E, Antor M, Salinas H. Self-expandable metal stents to treat gastric leaks. Surg Obes Relat Dis. 2006;2:570–2.CrossRefGoogle Scholar
  16. 16.
    Devlin A, Wright AS, Figueredo E, Alyea E, Hanley PW, Lucas MK, et al. Development of a porcine Roux-en-Y gastric bypass survival model for the study of post-surgical physiology. Obes Surg. 2007;17:1332–9.CrossRefGoogle Scholar
  17. 17.
    Scott DJ, Provost DA, Tesfay ST, Jones DB. Laparoscopic Roux-en-Y gastric bypass using the porcine model. Obes Surg. 2001;11:46–53.CrossRefGoogle Scholar
  18. 18.
    Freeman RK, Ascioti AJ, Wozniak TC. Postoperative esophageal leak management with the Polyflex esophageal stent. J Thorac Cardiovasc Surg. 2007;133:333–8.CrossRefGoogle Scholar
  19. 19.
    Gelbmann CM, Ratiu NL, Rath HC, Rogler G, Lock G, Scholmerich J, et al. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy. 2004;36:695–9.CrossRefGoogle Scholar
  20. 20.
    Tsereteli Z, Sporn E, Geiger T, Miedema BW, Rangnekar N, Thaler K. Placement of a temporary covered stent supports healing of a colorectal anastomosis: observations in a large animal model. Surgery. 2008 (in press).Google Scholar
  21. 21.
    Eisendrath P, Cremer M, Himpens J, Cadiere GB, Le Moine O, Deviere J. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy. 2007;39:625–30.CrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2008

Authors and Affiliations

  • Emanuel Sporn
    • 1
  • Brent W. Miedema
    • 1
  • J. Andres Astudillo
    • 1
  • Klaus Thaler
    • 1
    Email author
  1. 1.Department of SurgeryUniversity of MissouriColumbiaUSA

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