Endolumenal treatment of Sleeve gastrectomy leaks
Leaks are major adverse events associated with higher overall complication rates, higher mortality rates, and longer length of stay. The mainstays of treatment entail not only local but also systemic therapy. In this case, systemic therapy includes adequate drainage (either internal or external), infection control by broad-spectrum intravenous antibiotics, establishing a dietary route (enteral is preferred over total parenteral nutrition), and chemoprophylaxis for deep venous thrombosis.
Accordingly, treating leaks demand a well-coordinated multidisciplinary team and daily panel discussion on the patient’s clinical status. As to the local treatment, the clinical stability at presentation is central for deciding between the operative and non-operative therapeutic modality. Patients with diffuse abdominal pain and peritonitis or those clinically unstable should be referred to emergency surgery. In the absence of those signs, non-operative treatment is recommended.
Endoscopic modalities are local therapies that should accompany the above-mentioned systemic treatment. There are three physiologically distinct groups of endoluminal techniques: internal drainage, closure, and diversion. They are not mutually exclusive, and on the contrary, they should be combined to achieve higher resolution rates while minimizing adverse events.
The first step of the non-operative management is to confirm that the leak or adjacent collection has adequate drainage. That is key since the gastrointestinal fluid is always contaminated and may lead to peritonitis, sepsis, or abscess formation if not properly addressed. Surgical drains from the primary procedure are usually enough to guarantee fluid flow. In the absence of surgical drains, the patient should be referred to surgical, endoscopic, or interventional radiology drainage. The choice should be at the discretion of the multidisciplinary team. Determinant factors in deciding among those modalities include local expertise, availability, and the distance between the orifice and the collection.
The second step is to identify and treat factors that impair healing, such as a distal stricture or foreign bodies inside the leak orifice (drains or lose staples). If present, distal strictures should be dilated, and foreign bodies should be removed.
Finally, the endoscopist should employ a local therapy to expedite the leak closure. Several procedures, techniques, and devices are currently available in this setting: self-expandable metallic stents (SEMS), double-pigtail stents (DPS), endoscopic-assisted vacuum therapy (EVT), septotomy, over-the-scope clips, sealants, biomaterial plugs, and endoscopic suturing.
References
Brunaldi VO, Galvao Neto M, Zundel N, et al. Isolated sleeve gastrectomy stricture: a systematic review on reporting, workup, and treatment. Surg Obes Relat Dis Off J Am Soc Bariatr Surg 2020; 16: 955–966. doi:10.1016/j.soard.2020.03.006
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: 1788–1796. doi:10.1007/s11695-018-3236-6