Use of endoscopic septotomy for the treatment of late staple-line leaks after laparoscopic sleeve gastrectomy

Abstract

Background Staple-line leak following laparoscopic sleeve gastrectomy is a dire adverse event. While the treatment of acute and early leaks is well established, there is still dispute regarding late and chronic leaks. We describe an endoscopic approach combining septotomy and sleeve stricture dilation for treating late/chronic leaks.

Methods Ten consecutive patients with late/chronic proximal leaks were treated at our center. The septum separating the sleeve lumen from the perigastric cavity was progressively dissected over several sessions and the downstream stricture was pneumatically dilated. The technical and clinical success rates were evaluated.

Results: All ten patients were treated successfully. Eight patients had sleeve strictures that were dilated in conjunction with septotomy. A mean of five sessions over the course of 43 days was needed to complete treatment. In two patients with a small perigastric cavity and no stricture, septotomy was achieved with through-the-scope balloon dilation of the fistula. No adverse events were encountered.

Conclusions Septotomy accompanied by stricture dilation seems highly effective and safe in late and chronic leaks following sleeve gastrectomy.

• References

• 1 Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013; 23: 427-436
• 2 Rosenthal RJ, Diaz AA. et al. International Sleeve Gastrectomy Expert Panel. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis 2012; 8: 8-19
• 3 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: 1291-1294
• 4 Puig CA, Waked TM, Baron Sr TH. et al. The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery. Surg Obes Relat Dis 2014; 10: 613-617
• 5 Mercky P, Gonzalez JM, Aimore Bonin E. et al. Usefulness of over-the-scope clipping system for closing digestive fistulas. Dig Endosc 2015; 27: 18-24
• 6 Keren D, Eyal O, Sroka G. et al. Over-the-scope clip (OTSC) system for sleeve gastrectomy leaks. Obes Surg 2015; 25: 1358-1363
• 7 Donatelli G, Dumont JL, Cereatti F. et al. Treatment of leaks following sleeve gastrectomy by endoscopic internal drainage (EID). Obes Surg 2015; 25: 1293-1301
• 8 Sharaiha RZ, Kumta NA, DeFilippis EM. et al. A large multicenter experience with endoscopic suturing for management of gastrointestinal defects and stent anchorage in 122 patients: a retrospective review. J Clin Gastroenterol 2016; 50: 388-392
• 9 Christophorou D, Valats JC, Funakoshi N. et al. Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study. Endoscopy 2015; 47: 988-996
• 10 Baretta G, Campos J, Correia S. et al. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc 2015; 29: 1714-1720
• 11 Campos JM, Pereira EF, Evangelista LF. et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011; 21: 1520-1529
• 12 Kumbhari V, Cai JX, Schweitzer MA. Endoscopic management of bariatric surgical complications. Curr Opin Gastroenterol 2015; 31: 359-367
• 13 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: 1400-1407
• 14 Nedelcu AM, Skalli M, Deneve E. et al. Surgical management of chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis 2013; 9: 879-884
• 15 Ramos AC, Ramos MG, Campos JM. et al. Laparoscopic total gastrectomy as an alternative treatment to postsleeve chronic fistula. Surg Obes Relat Dis 2015; 11: 552-556