An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video)
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Background and Aims
Endoscopic stenting has proved effective in the management of post-surgical leaks but is strongly hampered by the high rate of stent migration. In this study, we evaluate our experience with a new approach involving the use of novel ultra-large expandable stents tailored for bariatric surgery leaks (Mega stents), combined with the use of the innovative over-the-scope clips (OTSC).
Retrospective analysis of patients with post-bariatric surgery leaks managed at our institution by an approach combining Mega stents and over-the-scope clips.
Twenty-two patients were treated for post-bariatric surgery leaks; 13 (59 %) had a sleeve gastrectomy while nine (41 %) had a RYGB. A total of 30 stents were inserted. Successful endoscopic insertion and removal were achieved in all patients. OTSC clips were applied in 12 patients (55 %); five simultaneously with stents and seven after stent removal. Primary closure (after one endoscopic procedure) was achieved in 13 patients (59 %) and in a total of 18 patients after multiple endoscopic procedures (82 %). An average of 1.4 stents and 2.8 endoscopic procedures were required per patient. Stent migration occurred in four patients (18 %), and all were retrievable endoscopically. Other complications included retrosternal pain and vomiting in 20 patients (91 %) including one necessitating early removal, bleeding in two patients (9 %), and perforation and esophageal stricture in one patient each (5 %). Two mortalities were encountered, and one of them was stent-related (bleeding).
Mega stents are effective in the management of post-bariatric surgery leaks. The combined use of Mega stents and OTSC clips is associated with a low incidence of migration and a low number of stents and procedures required per patient.
KeywordsSleeve gastrectomy Gastric bypass Fistula Leak Stent Esophageal stent Oesophageal stent Clips Over-the-scope clips Surgical obesity complications Gastric leak
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Conflicts of Interest
The authors declare that they have no competing interests.
Informed consent was obtained from all individual participants included in this study.
A major leak was detected 2 days after a RYGB. Endoscopy was performed revealing dehiscence of more than half the circumference of the gastrojejunal anastomosis. The leak cavity was explored, pus was aspirated, and two OTSC clips were applied to approximate the leak edges. A Mega stent was inserted during the same session. Eight weeks later, the clips were seen in place but fell off while extracting the stent. Re-inspection revealed healing of the majority of the leak with persistence of a fibrotic tract. Argon plasma coagulation was used to refresh the edges of the fistulous tract. A second Mega stent was then inserted. Six weeks later, the stent was removed revealing complete healing of the gastrojejunal anastomosis. (MPG 76794 kb)
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