Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis

Abstract

Background: Endoscopic techniques have become the first-line therapy in bariatric surgery-related complications such as leaks and fistulas. We performed a systematic review and meta-analysis on the effectiveness of self-expandable stents, clipping, and tissue sealants in closing of post-bariatric surgery leak/fistula.

Methods: A systematic literature search of the Medline/Scopus databases was performed to identify full-text articles published up to February 2019 on the use of self-expandable stents, clipping, or tissue sealants as primary endoscopic strategies used for leak/fistula closure. Meta-analysis of studies reporting stents was performed with the PRISMA guidelines.

Results: Data concerning the efficacy of self-expanding stents in the treatment of leaks/fistulas after bariatric surgery were extracted from 40 studies (493 patients). The overall proportion of successful leak/fistula closure was 92% (95% CI, 90-95%). The overall proportion of stent migration was 23% (95% CI, 19-28%). Seventeen papers (98 patients) reported the use of clipping: the over-the-scope clips (OTSC) system was used in 85 patients with a successful closure rate of 67.1% and a few complications (migration, stenosis, tear). The successful fistula/leak closure using other than OTSC types was achieved in 69.2% of patients. In 10 case series (63 patients), fibrin glue alone was used with a 92.8-100% success rate of fistula closure that usually required repeated sessions at scheduled intervals. The complications of fibrin glue applications were reported in only one study and included pain and fever in 12.5% of patients.

Conclusions: Endoscopic techniques are effective for management of post-bariatric leaks and fistulas in properly selected patients.

Keywords: Bariatric; Endoscopic; Fistula; Gastric bypass; Leak; Sleeve.

Fig. 1

Flowchart for search strategy and selection of eligible studies for systemic review and meta-analysis

Fig. 2

Forest plot for successful leak closure. After exclusion of outliers: overall proportion of successful leak closure = 92% (95% CI, 90–95%), test of heterogeneity I² = 0.00% (p = 0.77)

Fig. 3

Forest plot for successful leak closure in gastric sleeve group. After exclusion of outliers: overall proportion of successful leak closure = 92%, (95% CI, 88–95%), homogeneity coefficient was I² = 0.00% (p = 0.81)

Fig. 4

Forest plot for successful leak closure in gastric bypass group. After exclusion of outliers: overall proportion of successful leak closure = 96%, (95% CI, 91–100%), homogeneity coefficient was I² = 0.00% (p = 0.58)

Fig. 5

Forest plot for stent migration. After exclusion of outliers: overall proportion of stent migration = 23% (95% CI, 19–28%), test of heterogeneity I² = 3.36% (p = 0.41)