Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery.
BACKGROUND
Reoperations for complications of bariatric surgery are associated with high morbidity and mortality. It is not known whether endoscopic treatment may reduce reoperation rates.


METHODS
Twenty-one patients underwent endoscopic treatment for persisting large anastomotic leaks before considering redo surgery. Eight patients had a gastric bypass, eight had a sleeve gastrectomy combined with a duodenal switch (SDS), four had a sleeve gastrectomy alone, and one had a Scopinaro procedure (biliopancreatic diversion). Fistulas were gastrocutaneous in 15 patients, duodenocutaneous in 2, gastroperitoneal in 3, and gastrobronchial in 1. Partially covered self-expanding metal stents (SEMSs) were used, followed by additional endoscopic procedures if the SEMS failed. SEMSs were removed by traction alone or by insertion of a self-expanding plastic stent (SEPS) followed by extraction of both stents together.


RESULTS
SEMS insertion led to 62 % (13/21) primary closures. Complementary endoscopic treatment led to 4 secondary closures. Total success rate was 81 % (17/21). Three patients in whom SEMSs failed underwent reoperation but died during postoperative follow-up; one patient died from pulmonary embolism before SEMS extraction. The success rates of endotherapy were 100 % (8/8) in the gastric bypass group, 62.5 % (5/8) in the SDS group, 75 % (3/4) in the sleeve gastrectomy group, and 100 % (1/1) for the Scopinaro procedure. Gastrocutaneous fistulas on sleeve sutures were successfully treated in 60 % of cases (6/10), while other anastomotic fistulas were successfully treated in 100 % of cases (11/11) ( P = 0.0351).


CONCLUSIONS
Endoscopic treatment using SEMSs for complications of bariatric surgery is feasible. Healing of severe leaks was obtained in 81 % (17/21) of patients, avoiding high-risk reintervention. Gastrocutaneous fistulas on a sleeve suture are the most difficult condition to treat.
Eisendrath
P
P
Medical Surgical Department of Gastroenterology and Hepatopancreatology, Erasme Hospital, UniversitA libre de Bruxelles (U.L.B.), Brussels, Belgium. peisendr@ulb.ac.be
Cremer
M
M
Himpens
J
J
Cadière
G-B
GB
Le Moine
O
O
Devière
J
J
D000328:Adult; D050110:Bariatric Surgery / Q000009:adverse effects / Q000379:methods*; D020099:Coated Materials, Biocompatible; D020878:Device Removal; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005747:Gastric Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery; D011183:Postoperative Complications; D019919:Prosthesis Implantation / Q000295:instrumentation*; D011859:Radiography; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome
D020099:Coated Materials, Biocompatible