Skip to main content
SpringerLink
Log in

An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video)

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

An Erratum to this article was published on 05 November 2015

Abstract

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).

Methods

Retrospective analysis of patients with post-bariatric surgery leaks managed at our institution by an approach combining Mega stents and over-the-scope clips.

Results

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).

Conclusion

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients. What have we learned? Obes Surg. 2000;10:509–13.

    Article  CAS  PubMed  Google Scholar 

  2. Fernandez Jr AZ, DeMaria EJ, Tichansky DS. Experience with over 3000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc. 2004;18:193–7.

    Article  PubMed  Google Scholar 

  3. Chung MA, Wanebo HS. Surgical management and treatment of gastric and duodenal fistulas. Surg Clin N Am. 1996;76:1137–46.

    Article  CAS  PubMed  Google Scholar 

  4. Swinnen J, Eisendrath P, Rigaux J, et al. Self-expandable metal stents for the treatment of benign upper GI leaks and perforations. Gastrointest Endosc. 2011;73:890–9.

    Article  PubMed  Google Scholar 

  5. Bege T, Emungania O, Vitton V, et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc. 2011;73:238–44.

    Article  PubMed  Google Scholar 

  6. van Boeckel PG, Sijbring A, Vleggaar FP, et al. Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther. 2011;33:1292–301.

    Article  PubMed  Google Scholar 

  7. 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.

    Article  PubMed  Google Scholar 

  8. van Bodegraven AA, Kuipers EJ, Bonenkamp HJ, et al. Esophagopleural fistula treated endoscopically with argon beam electrocoagulation and clips. Gastrointest Endosc. 1999;50:407–9.

    Article  PubMed  Google Scholar 

  9. Basha J, Appasani S, Sinha SK, et al. Mega stents: a new option for management of leaks following laparoscopic sleeve gastrectomy. Endoscopy. 2014;46 Suppl 1 UCTN:E49-50

  10. Kirschniak A, Kratt T, Stuker D, et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc. 2007;66:162–7.

    Article  PubMed  Google Scholar 

  11. Galloro G, Magno L, Musella M, et al. A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series. Surg Obes Relat Dis. 2014;10:607–11.

    Article  PubMed  Google Scholar 

  12. Edwards CA, Bui TP, Astudillo JA, et al. Management of anastomotic leaks after Roux-en-Y by pass using self-expanding polyester stents. Surg Obes Relat Dis. 2008;4:594–9.

    Article  PubMed  Google Scholar 

  13. Leenders BJ, Stronkhorst A, Smulders FJ, et al. Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital. Surg Endosc. 2013;27:2751–9.

    Article  PubMed  Google Scholar 

  14. van Boeckel PG, Dua KS, Weusten BL, et al. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol. 2012;29:12–9.

    Google Scholar 

  15. Donatelli G, Dhumane P, Perretta S, et al. Endoscopic placement of fully covered self expanding metal stents for management of post-operative foregut leaks. J Minim Access Surg. 2012;8:118–24.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Inbar R, Santo E. Subchi Ael-A, et al. Insertion of a removable expandable stent as a treatment for postoperative leaks and perforations of the esophagus and stomach. Isr Med Assoc J. 2011;13:230–3.

    PubMed  Google Scholar 

  17. Feith M, Gillen S, Schuster T, et al. Healing occurs in most patients that receive endoscopic stents for anastomotic leakage; dislocation remains a problem. Clin Gastroenterol Hepatol. 2011;9:202–10.

    Article  PubMed  Google Scholar 

  18. Puig CA, Waked TM, Baron Sr TH, et al. The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery. Surg Obes Relat Dis. 2014;10:613–7.

    Article  PubMed  Google Scholar 

  19. Blackmon SH, Santora R, Schwarz P, et al. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg. 2010;89:931–6.

    Article  PubMed  Google Scholar 

  20. Shehab H, Elasmar H. Combined endoscopic techniques for closure of a chronic post-surgical gastrocutaneous fistula: case report and review of the literature (with video). Surg Endosc. 2013;27:2967–70.

    Article  PubMed  Google Scholar 

  21. Manta R, Manno M, Bertani H, et al. Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip (OTSC) device: case series from a tertiary referral center. Endoscopy. 2011;43:545–8.

    Article  CAS  PubMed  Google Scholar 

  22. Hagel AF, Naegel A, Lindner AS, et al. Over-the-scope clip application yields a high rate of closure in gastrointestinal perforations and may reduce emergency surgery. J Gastrointest Surg. 2012;16:2132–8.

    Article  PubMed  Google Scholar 

  23. Mennigen R, Colombo-Benkmann M, et al. Endoscopic closure of postoperative gastrointestinal leakages and fistulas with the Over-the-Scope Clip (OTSC). J Gastrointest Surg. 2013;17:1058–65.

    Article  PubMed  Google Scholar 

  24. Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;21:1520–9.

    Article  PubMed  Google Scholar 

  25. Donatelli G, Dumont JL, Cereatti F, et al. Treatment of leaks following sleeve gastrectomy by endoscopic internal drainage (EID). Obes Surg. 2015;25:1293–301.

    Article  CAS  PubMed  Google Scholar 

Download references

Ethical Standards

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

Informed consent was obtained from all individual participants included in this study.

Author information

Authors and Affiliations

  1. Gastrointestinal Endoscopy Unit, Gastroenterology Department, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt

    Hany M. Shehab

  2. Bariatric Surgery Department, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt

    Sherif M. Hakky

  3. General Surgery Department, Ain Shams University Hospital, Ain Shams University, Cairo, Egypt

    Khaled A. Gawdat

Authors
  1. Hany M. Shehab
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sherif M. Hakky
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Khaled A. Gawdat
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hany M. Shehab.

Electronic supplementary material

Below is the link to the electronic supplementary material.

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)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shehab, H.M., Hakky, S.M. & Gawdat, K.A. An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video). OBES SURG 26, 941–948 (2016). https://doi.org/10.1007/s11695-015-1857-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-015-1857-6

Keywords

Search

Navigation