Internal endoscopic drainage as first line or second line treatment in case of postsleeve gastrectomy fistulas

 

 Permissions and Reprints

Abstract

Background and study aims Management of post-sleeve gastrectomy fistulas (PSGF) recently has evolved, resulting in prioritization of internal endoscopic drainage (IED). We report our experience with the technique in a tertiary center.

Patients and methods This was a single-center, retrospective study of 44 patients whose PSGF was managed with IED, comparing two periods: after 2013 (Group 1; n = 22) when IED was used in first line and before 2013 (Group 2; n = 22) when IED was applied in second line. Demographic data, pre-endoscopic management, characteristics of fistulas, therapeutic modalities and outcomes were recorded and compared between the two groups. The primary endpoint was IED efficacy; the secondary endpoint was a comparison of outcomes depending on the timing of IED in the management strategy.

Results The groups were matched in gender (16 female, 16 male), mean age (43 years old), severity of fistula, delay before treatment, and exposure to previous endoscopic or surgical treatments. The overall efficacy rate was 84 % (37/44): 86 % in Group 1 and 82 % in Group 2 (NS). There was one death and one patient who underwent surgery. The median time to healing was 226 ± 750 days (Group 1) vs. 305 ± 300 days (Group 2) (NS), with a median number of endoscopies of 3 ± 6 vs. 4.5 ± 2.4 (NS). There were no differences in number of nasocavity drains and double pigtail stents (DPS), but significantly more metallic stents, complications, and secondary strictures were seen in Group 2.

Conclusion IED for management of PSGF is effective in more than 80 % of cases whenever it is used during the therapeutic strategy. This approach should be favored when possible.

• References

• 1 Moszkowicz D, Arienzo R, Khettab I. et al. Sleeve gastrectomy severe complications: is it always a reasonable surgical option?. Obes Surg 2013; 23: 676-686
  CrossrefPubMedGoogle Scholar
• 2 Rosenthal RJ, International SleeveGastrectomy Expert Panel, Diaz AA. et al. 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
  CrossrefPubMedGoogle Scholar
• 3 Basdevant A, Coupaye M, Charles MA. Définition, épidémiologie, origines, conséquences et traitement des obésités de l'adulte. In: Chevallier JM, Pattou F. eds. Association française de chirurgie, Chirurgie de l'obésité. Rapport présenté au 106e congrès français de chirurgie. Paris: Arnette; 2004: 3-28
  Google Scholar
• 4 Buchwald H, Avidor Y, Braunwald E. et al. Bariatric Surgery. JAMA 2004; 292: 1724
  CrossrefPubMedGoogle Scholar
• 5 Fuks D, Verhaeghe P, Brehant O. et al. Results of laparoscopic sleeve gastrectomy: A prospective study in 135 patients with morbid obesity. Surgery 2009; 145: 106-113
  CrossrefPubMedGoogle Scholar
• 6 Voermans RP, Le MoineO, von Renteln D. et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol 2012; 10: 603-608
  CrossrefPubMedGoogle Scholar
• 7 Mercky P, Gonzalez J-M, Aimore BoninE. et al. Usefulness of over-the-scope clipping system for closing digestive fistulas. Dig Endosc 2015; 27: 18-24
  CrossrefPubMedGoogle Scholar
• 8 Surace M, Mercky P, Demarquay J-F. et al. Endoscopic management of GI fistulae with the over-the-scope clip system (with video). Gastrointest Endosc 2011; 74: 1416-1419
  CrossrefPubMedGoogle Scholar
• 9 Bonanomi G, Prince JM, McSteen F. et al. Sealing effect of fibrin glue on the healing of gastrointestinal anastomoses: implications for the endoscopic treatment of leaks. Surg Endosc 2004; 18: 1620-1624
  PubMedGoogle Scholar
• 10 Papavramidis TS, Kotzampassi K, Kotidis E. et al. Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch. J Gastroenterol Hepatol 2008; 23: 1802-1805
  CrossrefPubMedGoogle Scholar
• 11 Papavramidis ST, Eleftheriadis EE, Papavramidis TS. et al. Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant. Gastrointest Endosc 2004; 59: 296-300
  CrossrefPubMedGoogle Scholar
• 12 Eisendrath P, Cremer M, Himpens J. et al. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy 2007; 39: 625-630
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 Bège T, Emungania O, Vitton V. et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc 2011; 73: 238-244
  CrossrefPubMedGoogle Scholar
• 14 van Boeckel PGA, Dua KS, Weusten BLAM. et al. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012; 12: 19
  CrossrefPubMedGoogle Scholar
• 15 Puig CA, Waked TM, Baron 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
  CrossrefPubMedGoogle Scholar
• 16 Murino A, Arvanitakis M, Le MoineO. et al. Effectiveness of endoscopic management using self-expandable metal stents in a large cohort of patients with post-bariatric leaks. Obes Surg 2015; 25: 1569-1576
  CrossrefPubMedGoogle Scholar
• 17 Gonzalez J-M, Garces DuranR, Vanbiervliet G. et al. Double-type metallic stents efficacy for the management of post-operative fistulas, leakages, and perforations of the upper gastrointestinal tract. Surg Endosc 2015; 29: 2013-2018
  CrossrefPubMedGoogle Scholar
• 18 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
  CrossrefPubMedGoogle Scholar
• 19 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
  CrossrefPubMedGoogle Scholar
• 20 Pequignot A, Fuks D, Verhaeghe P. et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?. Obes Surg 2012; 22: 712-720
  CrossrefPubMedGoogle Scholar
• 21 Bouchard S, Eisendrath P, Toussaint E. et al. Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract. Endoscopy 2016; 48: 809
  Article in Thieme ConnectPubMedGoogle Scholar
• 22 Swinnen J, Eisendrath P, Rigaux J. et al. Self-expandable metal stents for the treatment of benign upper GI leaks and perforations. Gastrointest Endosc 2011; 73: 890-899
  CrossrefPubMedGoogle Scholar
• 23 El MouradH, Himpens J, Verhofstadt J. Stent treatment for fistula after obesity surgery: results in 47 consecutive patients. Surg Endosc 2013; 27: 808-816
  CrossrefPubMedGoogle Scholar
• 24 Leeds SG, Burdick JS. Management of gastric leaks after sleeve gastrectomy with endoluminal vacuum (E-Vac) therapy. Surg Obes Relat Dis 2016; 12: 1278-1285
  CrossrefPubMedGoogle Scholar
• 25 Smallwood NR, Fleshman JW, Leeds SG. et al. The use of endoluminal vacuum (E-Vac) therapy in the management of upper gastrointestinal leaks and perforations. Surg Endosc 2016; 30: 2473-2480
  CrossrefPubMedGoogle Scholar
• 26 Bludau M, Hölscher AH, Herbold T. et al. Management of upper intestinal leaks using an endoscopic vacuum-assisted closure system (E-VAC). Surg Endosc 2014; 28: 896-901
  CrossrefPubMedGoogle Scholar
• 27 Shnell M, Gluck N, Abu-Abeid S. et al. Use of endoscopic septotomy for the treatment of late staple-line leaks after laparoscopic sleeve gastrectomy. Endoscopy 2017 49: 59-63
  PubMedGoogle Scholar