Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results

Abstract

Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.

Keywords: Bariatric complications; Bariatric surgery; Endoscopic treatment; Gastric Roux-en-Y bypass; Leaks; Sleeve gastrectomy; Stenosis.

Figure 1

Bariatric surgery procedures. A: Adjustable gastric band; B: Roux-en-Y gastric bypass; C: Sleeve gastrectomy; D: Sleeve gastrectomy with biliopancreatic diversion.

Figure 2

Large collections requiring lavage to eliminate pus and debris. A: Early fluid collection after RYGB; B and C: Transfistulary drainage of the fluid collection. A 10 Fr double pigtail was placed; D: Nine days after stent placement the collection significantly reduced and became a virtual cavity. Yellow arrow: Double pigtail stent; white arrow: Reduced cavity after drainage. RYGB: Roux-en-Y gastric bypass.

Figure 3

Hanarostent^® (MI-tech, Seoul, South Korea). Fully-covered self-expandable stent adapted to the sleeve gastrectomy anatomy.

Figure 4

Over-the-scope clip (Ovesco Endoscopy, Tübingen, Germay). The over-the-scope clip attached to the gastroscope tip and ready to be placed on the wall defect. At the bottom of the figure, different available sizes of over-the-scope clip in the final position once they have been released.

Figure 5

Upper gastrointestinal series displaying a small gastrogastric fístula ten days after Roux-en-Y gastric bypass (arrows).

Figure 6

Leak resolution after stent deployement. A: The same gastrogastric fistula (arrow) as in Figure 5 confirmed by CT scan with oral water-soluble contrast. A fully covered self-expandable metal stent was inserted. The stent was removed after forty three days and a complimentary injection of fibrin glue was performed; B: A new CT scan revelaed the fistula closure. CT: Computed tomography.

Figure 7

Management algorithm for post-bariatric surgery leaks. Leaks have been classified based on the time period they appear as early, between first and fourth day post-operative, intermediate, between the fifth and ninth day after surgery, and late appearing after day ten. ^aSome authors prefer surgical repair in early small-volume leaks; ^bExcept in uncomplicated small early leaks where conservative treatment has 75% of success in leak closure and the potential benefits of SEES are shadowed by the risk of migration and related complications. SEMS: Self-expanding metal stent; OTSC: Over-the-scope clip.

Figure 8

Endoscopic retrograde cholangiopancreatography approaches in Roux-en-Y gastric bypass. A: Laparoscopic-assisted endoscopic retrograde cholangiopancreatography; B: Endoscopically-assisted endoscopic retrograde cholangiopancreatography.