Endoscopic stenting for laparoscopic sleeve gastrectomy leaks

Abstract

Objective: Laparoscopic sleeve gastrectomy is a widely accepted and effective bariatric surgery method. The rate of leakage at the staple-line has been reported to be between 1.5 and 5%. Aside from the use of percutaneous drainage, re-laparoscopy, or abdominal sepsis control by laparotomy, endoscopic esophagogastric stent placement is increasingly preferred as a treatment method. Because laparoscopic sleeve gastrectomy is a widely used modality in our hospital, we aimed to evaluate the rate of leaks and the results of stent placements in our patients.

Material and methods: Between January 1^st 2010 and August 31^st 2014, laparoscopic sleeve gastrectomy was performed on 236 patients by three surgeons. The demographic information and postoperative discharge summaries were collected and analyzed with the permission of the hospital ethics committee. Information about leak treatment management was also collected.

Results: Leaks after laparoscopic sleeve gastrectomy in four patients were stented in the first postoperative month. Short (12 cm) Hanora® (M.I.Tech, Gyeonggi-do, Korea) self-expandable coated stents were placed in two patients, and long (24 cm) Hanora® self-expandable coated stents were placed in the other two. The stents were removed after one month in two patients, two and a half months later in one, and five months later in another patient. The leaks were demonstrated to be healed in all patients after stent removal. Endoscopic stent revision was performed in one patient due to migration of the stent and in another for stent breakage.

Conclusion: The success rate of treatment of leaks after laparoscopic sleeve gastrectomy by stent placement has been variable in the literature. The success in early stent placement has been shown to be related to physician expertise. According to the results of our patients, we suggest that endoscopic stent placement in the early stage after controlling sepsis is an effective method in the management of leaks.

Keywords: Complications; endoscopic; fistula; laparoscopic sleeve gastrectomy; leak; management; stent.

Figure 1. a–c

A staple-line leak near the gastroesophageal junction (a). The stent was introduced over a guide wire placed under direct vision (b). Then, the stent was opened to cover the leak (c)

Figure 2. a, b

There was a recurrent discharge from the drain area; however, fistulography showed a blind sinus (a), and the stent was in proper position (b)

Figure 3. a, b

Initial CT scan showed normal findings (a), but 2 days later, the CT scan detected wide areas of free fluid in the abdomen (b)

Figure 4. a–c

Leaks were closed with exudated floors (a–c). The stapler (b) and suture material (c) were visible in the oesophageal lumen

Figure 5. a–c

Mucosal ingrowth through the distal portion of the stent