Skip to main content
SpringerLink
Log in

Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis

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

Abstract

Background

Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results.

Methods

We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients’ clinical characteristics, duration and type of stent, other stent complications, and mortality.

Results

A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52–89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32–22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94–17.14%). The agreement between reviewers for the collected data gave a Cohen’s κ value of 1.0. No deaths were caused directly by complications with the stent placement.

Conclusions

Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.

Graphical abstract

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

Access this article

Log in via an institution

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
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Welbourn R, Hollyman M, Kinsman R, et al. Bariatric surgery worldwide: baseline demographic description and one-year outcomes from the fourth IFSO Global Registry Report 2018. Obes Surg. 2018.

  2. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the global burden of disease study 2013. Lancet. 2014;384:766–81.

    PubMed  PubMed Central  Google Scholar 

  3. The International Federation for the Surgery of Obesity and Metabolic Disorders. Fifth IFSO Global Registry Report. https://www.ifso.com/ifso-registry.php. Published 2019.

  4. American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers—American Society for Metabolic and Bariatric Surgery. www.asmbs.org. https://asmbs.org/resources/ estimate-of-bariatric-surgery-numbers. Published 2018.

  5. Ma IT, Madura JA. Gastrointestinal Complications After Bariatric Surgery. Gastroenterol Hepatol (N Y). 2015;11(8):526–35.

    Google Scholar 

  6. Gero D, Raptis DA, Vleeschouwers W, et al. Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy. Ann Surg. 2019;270(5):859–67.

    PubMed  Google Scholar 

  7. Gero D, Vannijvel M, Okkema S, et al. Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures. Ann Surg. 2021;274(5):821–8.

    PubMed  Google Scholar 

  8. Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obes Surg. 2004;14(10):1290–8.

    PubMed  Google Scholar 

  9. Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26(6):1509–15.

    PubMed  Google Scholar 

  10. Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of %3e12,000 cases. Surg Obes Relat Dis. 2012;8(1):8–19.

    PubMed  Google Scholar 

  11. Blachar A, Federle MP, Pealer KM, et al. Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings. Radiology. 2002;223(3):625–32.

    PubMed  Google Scholar 

  12. Mathus-Vliegen EM. The cooperation between endoscopists and surgeons in treating complications of bariatric surgery. Best Pract Res Clin Gastroenterol. 2014 28(4):703–25.

    CAS  PubMed  Google Scholar 

  13. Iannelli A, Treacy P, Sebastianelli L, et al.. Perioperative complications of sleeve gastrectomy: Review of the literature. J Minim Access Surg. 2019 15(1):1–7.

  14. Fernandez AZ Jr, DeMaria EJ, Tichansky DS, 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.

    PubMed  Google Scholar 

  15. Kim J, Azagury D, Eisenberg D, et al. American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoper- ative management. Surg Obes Relat Dis. 2015;11(4):739–48.

  16. Kanters AE, Shubeck SP, Varban OA, et al.. Incidence and efficacy of stent placement in leak management after bariatric surgery: an MBSAQIP analysis. Ann Surg. 2018. Advance online publication.

  17. Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg 2008;206:935–8; discussion 938–9.

  18. Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis. Gastrointest Endosc. 2012 75(2):287–93.

    PubMed  Google Scholar 

  19. Okazaki O, Bernardo WM, Brunaldi VO, et al. Efficacy and safety of stents in the treatment of fistula after bariatric surgery: a systematic review and meta-analysis. Obes Surg. 2018;28(6):1788–96.

    PubMed  Google Scholar 

  20. Rogalski P, Swidnicka-Siergiejko A, Wasielica-Berger J, et al.. Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis. Surg Endosc. 2020 Feb 27.

  21. Ebigbo A, Karstensen JG, Aabakken L, et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open. 2019;7(6):E833–6. https://doi.org/10.1055/a-0898-3523.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Moher D, Shamseer L, Clarke M, et al.. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.

  23. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 2000;283: 2008–12.

  24. Brennan P, Silman A. Statistical methods for assessing observer variabilityin clinical measures. BMJ. 1992;304:1491–4.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Bruce J, Krukowski ZH, Al-Khairy G, et al. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg. 2001;88(9):1157–68.

    CAS  PubMed  Google Scholar 

  26. Murad MH, Sultan S, Haffar S, et al. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med. 2018;23(2):60–3. https://doi.org/10.1136/bmjebm-2017-110853.

    Article  PubMed  PubMed Central  Google Scholar 

  27. DerSimonian R, Laird N. Meta-analysis in clinical trials revisited. Contemp Clin Trials. 2015;45(Pt A):139–45.

    PubMed  PubMed Central  Google Scholar 

  28. Normand S-L.T., NormandTutorial in biostatistics. Meta-analysis: formulating, evaluating, combining, and reporting, Statistics in Medicine, 18, 321–359 (1999).

  29. Deeks J.J., Systematic reviews in health care: systematic reviews of evaluations of diagnostic and screening tests. BMJ, 323, 157-62 (2001)

  30. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Statististics in Medicine. 2002;21:1539–58.

    Google Scholar 

  31. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50:1088–101.

    CAS  PubMed  Google Scholar 

  32. Salinas A, Baptista A, Santiago E, et al. Self-expandable metal stents to treat gastric leaks. Surg Obes Relat Dis. 2006;2:570–2.

    PubMed  Google Scholar 

  33. Eisendrath P, Cremer M, Himpens J, et al. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy. 2007;39:625–30.

    CAS  PubMed  Google Scholar 

  34. Fukumoto R, Orlina J, McGinty J, et al. Use of polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery. Surg Obes Relat Dis 2007;3:68–71; discussion 71–2.

  35. Serra C, Baltasar A, Andreo L, et al. Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy. Obes Surg. 2007;17:866–72.

    PubMed  Google Scholar 

  36. Casella G, Soricelli E, Rizzello M, et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg. 2009;19:821–6.

    CAS  PubMed  Google Scholar 

  37. El Mourad H, Himpens J, Verhofstadt J. Stent treatment for fistula after obesity surgery: results in 47 consecutive patients. Surg Endosc. 2012;27(3):808–16.

    PubMed  Google Scholar 

  38. Marr B, Needleman B, Mikami D. Endoscopic Stenting for Treatment of Leaks Following Sleeve Gastrectomy. World Journal of Laparoscopic Surgery, September-December. 2012;5(3):139–42.

    Google Scholar 

  39. Simon F, Siciliano I, Gillet A, et al. Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time. Obes Surg. 2013;23(5):687–92.

    CAS  PubMed  Google Scholar 

  40. 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(8):2751–9.

    PubMed  Google Scholar 

  41. Alazmi W, Al-Sabah S, Ali DA, et al. Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature. Surg Endosc. 2014;28(12):3425–8.

    PubMed  Google Scholar 

  42. 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(4):607–11.

  43. Fishman S, Shnell M, Gluck N, et al. Use of sleeve-customized self-expandable metal stents for the treatment of staple-line leakage after laparoscopic sleeve gastrectomy. Gastrointest Endosc. 2015;81(5):1291–4.

    PubMed  Google Scholar 

  44. Périssé LG, Périssé PC, Bernardo JC. Endoscopic treatment of the fistulas after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Rev Col Bras Cir. 2015;42(3):159–64.

    PubMed  Google Scholar 

  45. van Wezenbeek MR, de Milliano MM, Nienhuijs SW, et al. A Specifically Designed Stent for Anastomotic Leaks after Bariatric Surgery: Experiences in a Tertiary Referral Hospital. Obes Surg. 2016;26(8):1875–80.

    PubMed  Google Scholar 

  46. Almadi MA, Bamihriz F, Alharbi O, et al. Use of Self-Expandable Metal Stents in the Treatment of Leaks Complicating Laparoscopic Sleeve Gastrectomy: A Cohort Study. Obes Surg. 2018;28(6):1562–70.

    PubMed  Google Scholar 

  47. Klimczak T, Klimczak J, Szewczyk T, et al. Endoscopic treatment of leaks after laparoscopic sleeve gastrectomy using MEGA esophageal covered stents. Surg Endosc. 2018;32(4):2038–45.

    PubMed  Google Scholar 

  48. Martin Del Campo SE, Mikami DJ, Needleman BJ, et al.. Endoscopic stent placement for treatment of sleeve gastrectomy leak: a single institution experience with fully covered stents. Surg Obes Relat Dis. 2018 Apr;14(4):453 461.

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

    PubMed  Google Scholar 

  50. Boerlage TCC, Houben GPM, Groenen MJM, et al. A novel fully covered double-bump stent for staple line leaks after bariatric surgery: a retrospective analysis. Surg Endosc. 2018;32(7):3174–80.

    PubMed  PubMed Central  Google Scholar 

  51. Krishnan V, Hutchings K, Godwin A, et al. Long-term outcomes following endoscopic stenting in the management of leaks after foregut and bariatric surgery. Surg Endosc. 2019;33(8):2691–5.

    PubMed  Google Scholar 

  52. Vedantam S, Roberts J. Endoscopic Stents in the Management of Bariatric Complications: Our Algorithm and Outcomes. Obes Surg. 2020;30(3):1150–8.

    PubMed  Google Scholar 

  53. Fernandez AZ Jr, DeMaria EJ, Tichansky DS, 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.

    PubMed  Google Scholar 

  54. Podnos YD, Jimenez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg. 2003;138:957–61.

    PubMed  Google Scholar 

  55. Marshall JS, Srivastava A, Gupta SK, et al. Roux-en-Y gastric bypass leak complications. Arch Surg 2003;138:520–3; discussion 523–4.

  56. Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204:47–55.

    PubMed  Google Scholar 

  57. Ballesta C, Berindoague R, Cabrera M, et al. Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2008;18:623–30.

    PubMed  Google Scholar 

  58. Carucci LR, Conklin RC, Turner MA. Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of leak into excluded stomach with upper gastrointestinal examination. Radiology. 2008;248:504–10.

    PubMed  Google Scholar 

  59. Aranez J, Singh A, Bain A. Endoscopic closure of a gastric sleeve leak by using an over-the-scope clip and fully covered esophageal stent. Gastrointest Endosc. 2015;82(2):404.

    PubMed  Google Scholar 

  60. Kotzampassi K, Eleftheriadis E. Tissue sealants in endoscopic applications for anastomotic leakage during a 25-year period. Surgery. 2015;157(1):79–86.

    PubMed  Google Scholar 

  61. Haito-Chavez Y, Law JK, Kratt T, et al. International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video). Gastrointest Endosc. 2014 80(4):610–22.

    PubMed  Google Scholar 

  62. Bartell N, Bittner K, Kaul V, et al. Clinical efficacy of the over-the-scope clip device: A systematic review. World J Gastroenterol. 2020;26(24):3495–516.

    PubMed  PubMed Central  Google Scholar 

  63. Rábago LR, Ventosa N, Castro JL, et al. Endoscopic treatment of postoperative fistulas resistant to conservative management using biological brin glue. Endoscopy. 2002;34:632–8.

    PubMed  Google Scholar 

  64. Pramateftakis MG, Vrakas G, Kanellos I, et al. Endoscopic application of n-butyl-2-cyanoacrylate on esophagojejunal anastomotic leak: a case report. J Med Case Rep. 2011;5:96.

    PubMed  PubMed Central  Google Scholar 

  65. Assalia A, Ilivitzki A, Ofer A, et al. Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach. Surg Obes Relat Dis. 2018;14(8):1093–8.

    PubMed  Google Scholar 

  66. Kim J, et al. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015;11(4):739–48.

    PubMed  Google Scholar 

  67. Rodrigues-Pinto E, Morais R, Vilas-Boas F, et al. Role of endoscopic vacuum therapy, internal drainage, and stents for postbariatric leaks. VideoGIE. 2019;4(10):481–5.

    PubMed  PubMed Central  Google Scholar 

  68. Spota A, Cereatti F, Granieri S, et al. Endoscopic Management of Bariatric Surgery Complications According to a Standardized Algorithm. Obes Surg. 2021;31(10):4327–37.

    PubMed  Google Scholar 

  69. Debs T, Iannelli A, Frey S, et al. Mesenchymal Stem Cells and Platelet Rich Plasma Therapy to Treat Leak After Sleeve Gastrectomy. J Surg Res. 2021;268:405–10.

    CAS  PubMed  Google Scholar 

  70. Vargas EJ, Abu Dayyeh BK. Keep calm under pressure: a paradigm shift in managing postsurgical leaks. Gastrointest Endosc. 2018;87(2):438–41.

    PubMed  Google Scholar 

  71. Praveenraj P, et al. Management of gastric leaks after lapa- roscopic sleeve gastrectomy for morbid obesity: a tertiary care experience and design of a management algorithm. J Minim Access Surg. 2016;12(4):342–9.

    PubMed  PubMed Central  Google Scholar 

  72. Shaikh SN, Thompson CC. Treatment of leaks and fistulae after bariatric surgery. Tech Gastrointest Endosc. 2010;12(3):141–5.

    Google Scholar 

  73. 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(4):118–24.

    PubMed  PubMed Central  Google Scholar 

  74. Singer JL, Aryaie AH, Fayezizadeh M, et al. Predictive factors for the migration of endoscopic self-expanding metal stents placed in the foregut. Surg Innov. 2017;24(4):353–7.

    PubMed  Google Scholar 

  75. MK. Endoscopic approach for major complications of bariatric surgery. Clin Endosc. 2017;50(1):31–41.

  76. 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(5):890–9.

    PubMed  Google Scholar 

  77. Van den Berg MW, Kerbert AC, van Soest EJ, et al. Safety and efficacy of a fully covered large-diameter self-expanding metal stent for the treatment of upper gastrointestinal perforations, anas- tomotic leaks, and fistula. Dis Esophagus. 2016;29(6):572–9.

    PubMed  Google Scholar 

  78. Donatelli G, Ferretti S, Vergeau BM, et al. Endoscopic internal drainage with enteral nutrition (EDEN) for treatment of leaks following sleeve gastrectomy. Obes Surg. 2014;24(8):1400–7.

    PubMed  Google Scholar 

  79. Pequignot A, Fuks D, Verhaeghe P, et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy? Obes Surg. 2012;22(5):712–20.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General Surgery, University General Hospital, Castellon, Spain

    Andreu Martínez Hernández, Homero Beltrán Herrera, Miguel Ibáñez Belenguer, Raquel Queralt Martín, Ana Karina Maiocchi Segredo, Elena Aliaga Hilario & José Manuel Laguna Sastre

  2. Department of Mathematics, Jaume I University, Castellon, Spain

    Vicente Martínez García

  3. Jaume I Univeristy, Castellon, Spain

    José Manuel Laguna Sastre

Authors
  1. Andreu Martínez Hernández
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Homero Beltrán Herrera
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Vicente Martínez García
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Miguel Ibáñez Belenguer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Raquel Queralt Martín
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ana Karina Maiocchi Segredo
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Elena Aliaga Hilario
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. José Manuel Laguna Sastre
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andreu Martínez Hernández.

Ethics declarations

Ethics Approval

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.

Informed Consent

For this type of study, formal consent is not required from all individual participants included in th study. Informed consent was obtained from the patient to publish these images.

Conflict of Interest

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 33 KB)

Supplementary file2 (DOCX 116 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Martínez Hernández, A., Beltrán Herrera, H., Martínez García, V. et al. Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis. OBES SURG 32, 1034–1048 (2022). https://doi.org/10.1007/s11695-022-05890-8

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-022-05890-8

Keywords

Search

Navigation