title: An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video).
abstract: OBJECTIVE
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Gastrointestinal Endoscopy Unit, Gastroenterology Department, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt. h.shehab@kasralainy.edu.eg.
authors.forename: Hany M
authors.initials: HM
authors.lastname: Shehab
authors.affiliation: Bariatric Surgery Department, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt.
authors.forename: Sherif M
authors.initials: SM
authors.lastname: Hakky
authors.affiliation: General Surgery Department, Ain Shams University Hospital, Ain Shams University, Cairo, Egypt.
authors.forename: Khaled A
authors.initials: KA
authors.lastname: Gawdat
mesh_terms: D000328:Adult; D000368:Aged; D050110:Bariatric Surgery / Q000009:adverse effects*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005402:Fistula / Q000209:etiology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies; D015607:Stents; D013525:Surgical Instruments; D016896:Treatment Outcome
keywords: Clips; Esophageal stent; Fistula; Gastric bypass; Gastric leak; Leak; Oesophageal stent; Over-the-scope clips; Sleeve gastrectomy; Stent; Surgical obesity complications