Endoscopic internal drainage by double pigtail stents in the management of laparoscopic sleeve gastrectomy leaks

BackgroundLeaks and fistulas after laparoscopic sleeve gastrectomy (SG) are major adverse events of bariatric surgery. Endoscopic management of post-SG leaks has evolved from closure with covered self-expanding metallic stents to endoscopic internal drainage (EID).ObjectiveTo report our experience with the management of post-SG leaks treated with EID, either as primary therapy or after failure of closure therapy with self-expanding metallic stents.SettingSingle-center observational study.MethodsA retrospective study of 20 patients treated for post-SG leaks with EID by deployment of double pigtail stents across the leak orifice, positioning one end inside the collection and the other end in the lumen of the stomach.ResultsThere were 13 (65%) males and 7 (35%) females with a mean age of 34.2 ± 11.6 years. EID was performed after a mean 62 days after SG. Three patients had gastrobronchial fistula. Seventeen (85%) patients had failed some form of prior therapy for the leak. The mean duration of EID was 83 days and 17 (85%) patients had complete healing of the leak with a mean follow-up of 16 months. There were 2 (10%) adverse events and no mortalities. The success of EID in healing post-SG leak was significantly associated with the absence of a gastrobronchial fistula (P < .05).ConclusionsEID is an effective and safe endoscopic treatment of leaks after SG and is well tolerated. It allows early feeding and has fewer adverse events than other techniques. The presence of a gastrobronchial fistula is associated with higher failure rates. Long-term follow-up confirms a good outcome with no mortality.     

Endoscopic stent placement for treatment of sleeve gastrectomy leak: a single institution experience with fully covered stents

Background

Laparoscopic sleeve gastrectomy (SG) has risen in prevalence as a standalone surgical option for treating obesity over the last 15 years. One of the most worrisome complications is development of a leak at the gastrectomy staple line.

Fatal aortoesophageal fistula bleeding after stenting for a leak post sleeve gastrectomy

Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents (SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwent a computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.     

Gastric leak after sleeve gastrectomy: risk factors for poor evolution under conservative management

BackgroundGastric leak (GL) is the most highly feared early postoperative complication after sleeve gastrectomy (SG), with an incidence of 1% to 2%. This complication may require further surgery/endoscopy, with a risk of management failure that may require additional surgery, including total gastrectomy, leading to a risk of mortality of 0% to 9%.ObjectivesAssess the impact of factors that may lead to a poorer evolution of GL.SettingUniversity Hospital, France, public practice.MethodsThis was a retrospective, single-center study of a group of patients managed for GL after SG between November 2004 and January 2019 (n = 166). Forty-three patients were excluded. The population study was divided into 2 groups: patients with easy closing of the GL (n = 73) and patients with difficult closing of the GL or failure to heal (n = 50). Patients were allocated to 1 of 2 groups depending on the time to heal (median time of 84 days). The study's primary efficacy endpoint was to determine the risk factors for a poorer evolution of GL.ResultsAmong 123 patients included in this study, 103 patients had undergone primary SG (83.7%). The mean time to the appearance of GL was 15.1 days (range, 1–156 d). Seventy-four patients underwent a reoperation (60%). The mean number of endoscopies per patient was 2.7 (range, 2–7 endoscopies). The mean time to healing was 89.5 days (range, 18–386 d). There were 8 cases of healing failure (6.5%). Multivariate analysis identified body mass index (>47 kg/m²), time to referral (>2 d), and serum prealbumin level (<.1 g/dL) to be independent risk factors for a poorer evolution of GL.ConclusionImprovement of nutritional status before SG and early referral for GL could reduce the risk of delayed closure or the need for further surgery.     

Endoscopy management of sleeve gastrectomy stenosis: what we learned from 202 consecutive patients

BackgroundGastric sleeve stenosis (GSS) is described in 1%–4% of patients.ObjectiveTo evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis.SettingRetrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center.MethodsWe enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach was used.ResultsWe found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%.ConclusionGSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of the stenosis should guide the most suitable endoscopic approach.     

Endoscopic closure of persistent gastric leak and fistula following laparoscopic sleeve gastrectomy

IntroductionConservative management for gastric leak and fistulae after laparoscopic sleeve gastrectomy (LSG) often results in prolonged hospitalization as well as requirement of TPN or recurrent surgery (Casella et al., 2009) [1]. Endoscopically-placed stents are an additional non-invasive method, but are associated with the complication of stent migration in up to 50% of cases (Casella and co-workers, 2009) [1,4]. As other non-invasive means of treatment are absent, we believe this case demonstrates a new technique for multiple gastric leaks following LSG in patients without sepsis or peritonitis.Presentation of caseA patient developed a staple line gastric leak that persisted for 10 weeks following LSG despite multiple modalities of treatment. She refused to undergo stent placement, so via esophagogastroduodenoscopy (EGD), fistula margins were cauterized with argon plasma coagulation and a fibrin sealant was injected to include the surrounding area. Endoclips were placed along the fistula tracts. A repeat procedure was required. Follow up imaging confirmed resolution of gastric leak and patient did not experience additional complications.DiscussionThe patient was able to discontinue TPN and return to an oral diet. Both procedures were well tolerated and did not require hospitalization.ConclusionEndoscopic management of multiple gastric leaks and fistulae using fibrin seal, endoclips, and cauterization appears to be a promising noninvasive form of treatment with a lower associated morbidity and shortened hospitalization.     

Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review

Gastric leak remains the main complication after sleeve gastrectomy, but there are no standardized guidelines for its treatment. Good results have been reported using endoscopic double-pigtail stent. To estimate its effectiveness, we carried out this systematic review. Eleven eligible articles were identified by searching PubMed, Embase, and Cochrane Library databases. A total of 385 patients met the inclusion criteria. The pooled proportion of successful leak closures by using double pigtail drainage was 83.41%. The proportion of successful leak closures by using double pigtail drainage by experienced operators as first-line treatment was 84.71%. Our review suggested that double-pigtail stent could be a valid approach to manage the postbariatric gastric leak, with low rate of complications and a good tolerance by patients. More high-quality studies with large samples sizes should be undertaken to better evaluate and compare the variety of techniques available.     

Comparative use of different techniques for leak and bleeding prevention during laparoscopic sleeve gastrectomy: A multicenter study

BackgroundLaparoscopic sleeve gastrectomy (LSG) is an approved primary procedure for morbid obesity, but it is associated with serious complications, such as staple line leaks and bleeding. The objective of this study was to assess the effectiveness of staple line reinforcement (SLR) in reducing leaks and bleeding after LSG.MethodsA total of 1162 patients underwent LSG (305 males, 857 females). The mean age was 43.7 years and the mean body mass index was 48 kg/m². The patients were divided into 6 groups based on the type of SLR, including a no-SLR control group, with evaluation of leaking and bleeding risk and correlation of patients’ characteristics with complications.ResultsA total of 189 patients underwent LSG without reinforcement. The SLR method was oversewing in 476 patients, bovine pericardium in 312, synthetic polyester in 76, glycolide/trimethylene copolymer in 63, and thrombin matrix in 46. The overall leak frequency was 2.8%; higher with synthetic polyester (7.8%), 4.8% with no reinforcement, and lower with bovine pericardium strips (.3%; P<.01). Postoperative hemorrhage occurred in 35 patients (3%), with a higher frequency being observed without SLR (13.7%; P = .02). Only diabetes was a risk-factor for a leak (P< .01).ConclusionSLR with bovine pericardium strips significantly reduced the leak risk. Postoperative bleeding was significantly lower with all SLR-methods, although there was no significant difference among the various techniques. Patients with type II diabetes had a higher risk of staple line leak after LSG. Further randomized, controlled studies are needed to improve our understanding of the efficacy of SLR during LSG.     

Kidney transplantation after sleeve gastrectomy in the morbidly obese candidate: results of a 2-year experience

BackgroundMorbid obesity serves as a barrier to kidney transplantation (KT) due to potential suboptimal posttransplant outcomes. Laparoscopic sleeve gastrectomy (LSG) has previously been shown to improve transplant eligibility through weight loss.ObjectivesWe aimed to examine the role LSG plays in improving patient outcomes postrenal transplantation, including possible impact on new-onset diabetes after transplant (NODAT).SettingUniversity Hospital.MethodsA single-center analysis was performed identifying all patients who underwent KT after LSG from 2011 to 2017 (n = 41). Exclusion criteria included type I diabetes and previous pancreas transplantation. NODAT was defined as a new insulin requirement after KT. Delayed graft function was defined as need for dialysis within the first week after KT. Mean posttransplant follow-up period was 22 months.ResultsForty-one patients underwent KT after LSG after median time of 16 months. Median age of postLSG patients undergoing KT was 56.0 years at time of KT. Average body mass index decreased by 9 from the time of LSG to KT, and no patients regained weight at 1-year follow-up. After LSG, the number of patients with hypertension (85.4% versus 48.5%) and the number of antihypertensive medications used decreased significantly (1.6 versus .6) at time of KT (P < .001 each). At 1-year follow-up, the improvement in hypertension persisted (51.2% versus 48.5%, P = nonsignificant). The average insulin regimen decreased from 33.0 ± 51.6 to 11.7 ± 21.5 units at KT (P < .001). This improvement also persisted at 1-year follow-up (11.9 versus 11.7 units, P = nonsignificant). Zero patients suffered NODAT over the follow-up period (versus institutional rate of NODAT at 15.8%). One patient developed delayed graft function (2.4%, versus institutional rate of 13.3%). After 1 year postKT, there was 1 graft loss (2.4%) and no mortality.ConclusionThis is the largest reported series of KT after planned LSG in morbidly obese patients. Our results confirm excellent posttransplant outcomes among patients who otherwise would have been denied KT eligibility.     

Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass: a meta-analysis

BackgroundBariatric surgery could increase the risk of cholelithiasis, although it is unclear whether the incidence rates of cholelithiasis are similar after different bariatric procedures.ObjectivesTo compare the incidence rates of cholelithiasis after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in people with obesity.SettingMeta-analysis of cohort studies.MethodsWe searched the PubMed and Web of Science databases for relevant studies before December 2020, and estimated the summary odds ratios (OR) and 95% confidence intervals (CI) using a random-effects model or fixed-effects model, according to the heterogeneity.ResultsIn total, 8 cohort studies were included in this meta-analysis, and 94,855 and 106,844 participants received SG and RYGB, respectively. Compared with those receiving RYGB, the summary results showed that participants receiving SG had a 35% lower rate of cholelithiasis (OR, .65; 95% CI, .49–.86). Also, the participants receiving SG had a significantly lower incidence of cholecystectomy than those receiving RYGB (OR, .54; 95% CI, .30–.99). In a subgroup analysis, SG was associated with a significantly lower incidence of subsequent cholelithiasis than RYGB in both Western and non-Western countries. SG led to a significantly lower incidence of cholelithiasis than RYGB only when the follow-up was <2 years instead of over 2 years.ConclusionParticipants receiving SG had a significantly lower incidence of cholelithiasis than those receiving RYGB, particularly within the first 2 years after the bariatric surgery.     

Assessing risk factors,presentation, and management of portomesenteric vein thrombosis after sleeve gastrectomy: a multicenter case-control study

Background

Portomesenteric vein thrombosis (PMVT) is a rare complication of laparoscopic sleeve gastrectomy.

Increased adverse outcomes after laparoscopic sleeve gastrectomy in older super-obese patients: analysis of American College of Surgeons National Surgical Quality Improvement Program Database

Background

Laparoscopic sleeve gastrectomy (SG) has become the most popular bariatric operation over the last decade. Extreme obesity and increasing age have been generally associated with higher risks of complications after bariatric surgery. The postoperative risk for complications after SG has not been previously presented according to simultaneous grouping of body mass index (BMI) and age.

Weight loss specific to indication,remission of diabetes,and short-term complications after sleeve gastrectomy conversion to Roux-en-Y gastric bypass: a systematic review and meta-analysis

Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. Long-term complications such as insufficient weight loss (IWL) and gastroesophageal reflux disease (GERD) may necessitate SG conversion to Roux-en-Y gastric bypass (RYGB). The aim of this review was to determine the indication-specific weight loss and diabetes remission after SG conversion to RYGB (STOBY). Our objective was to extract all available published data on indication for conversion, weight loss, remission of diabetes, and short-term complications after STOBY. A systematic literature search was conducted to identify studies reporting outcomes following STOBY. A random effects model was used for meta-analysis. The search identified 44 relevant studies. Overall short-term (12-mo) excess weight loss (EWL) was 54.6% (95% confidence interval [CI], 46%–63%) in 23 studies (n = 712) and total weight loss (TWL) was 19.9% (95% CI, 14%–25%) in 21 studies (n = 740). For IWL, short-term (12-mo) pooled weight loss outcomes were 53.9% EWL (95% CI, 48%–59%) in 14 studies (n = 295) and 22.7% TWL (95% CI, 17%–28%) in 12 studies (n = 219), and medium-term (2–5 yr) outcomes were 45.8% EWL (95% CI, 38%–53%) in 7 studies (n = 154) and 20.6% TWL (95% CI, 15%–26%) in 9 studies (n = 206). Overall diabetes remission was 53% (95% CI, 33%–72%), and the perioperative complication rate was 8.2% (95% CI, 7.6%–8.7%). Revisional SG conversion to RYGB for IWL can achieve good weight loss outcomes and diabetes remission.     

Early morbidity and mortality of laparoscopic sleeve gastrectomy and gastric bypass in the elderly: a NSQIP analysis

BackgroundEven though the U.S. population is aging, outcomes of bariatric surgery in the elderly are not well defined. Current literature mostly evaluates the effects of gastric bypass (RYGB), with paucity of data on sleeve gastrectomy (SG). The objective of this study was to assess 30-day morbidity and mortality associated with laparoscopic SG in patients aged 65 years and over, in comparison to RYGB.MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for all patients aged 65 and over who underwent laparoscopic RYGB and SG between 2010 and 2011. Baseline characteristics and outcomes were compared. P value<.05 was considered significant. Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable.ResultsWe identified 1005 patients. Mean body mass index was 44±7. SG was performed in 155 patients (15.4%). The American Society of Anesthesiology physical classification of 3 or 4 was similar between the 2 groups (82.6% versus 86.7%, P = .173). Diabetes was more frequent in the RYGB group (43.2% versus 55.6%, P = .004). 30-day mortality (0.6% versus 0.6%, OR 1.1, 95% CI .11–9.49), serious morbidity (5.2% versus 5.6%, OR .91, 95% CI .42–0.96), and overall morbidity (9% versus 9.1%, OR 1.0, 95% CI .55–1.81) were similar.ConclusionIn elderly patients undergoing laparoscopic bariatric surgery, SG is not associated with significantly different 30-day outcomes compared to RYGB. Both procedures are followed by acceptably low morbidity and mortality.     

Potential mechanisms of sleeve gastrectomy for reducing weight and improving metabolism in patients with obesity

Obesity is a severe medical problem endangering the health of individuals worldwide. Sleeve gastrectomy (SG), one of the most commonly performed bariatric procedures, has been widely applied to the treatment of such patients. Currently, the potential mechanisms underlying the significant weight loss and metabolic improvement after SG have been well studied. First, and most importantly, by removing a large volume of stomach, the SG directly or indirectly restricts food intake. Then, there are alterations in the absorption and metabolism of both macro- and micronutrients, which may benefit or worsen the patients’ well-being. Another profound change is enhanced secretion of the satiety gut hormone and reduced secretion of the hunger hormone as a consequence of the operation. Additionally, adjustment of gastrointestinal motility, alteration in the gut microbial community, and an inflammatory response were found after surgery. Therefore, the purpose of the present review was focused on such hypotheses and to compile the accumulated facts on the physiologic mechanism of bariatric surgery so that these results can help improve the understanding of how SG produces substantial weight loss and a significant improvement in the metabolism of patients with metabolic syndrome.