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Endoscopic vacuum therapy for a large esophageal perforation after bariatric stent placement

Open AccessPublished:September 25, 2018DOI:https://doi.org/10.1016/j.vgie.2018.08.009

      Abbreviations:

      SEMS (self-expandable metal stent), SG (sleeve gastrectomy)
      Postoperative leaks pose a significant risk to patients undergoing sleeve gastrectomy (SG).
      • Marquez M.F.
      • Ayza M.F.
      • Lozano R.B.
      • et al.
      Gastric leak after laparoscopic sleeve gastrectomy.
      Currently, self-expandable metal stent (SEMS) placement is the mainstay of the treatment of early bariatric leaks.
      • Okazaki O.
      • Bernardo W.M.
      • Brunaldi V.O.
      • et al.
      Efficacy and safety of stents in the treatment of fistula after bariatric surgery: a systematic review and meta-analysis.
      The stent works by covering the orifice of the fistula and also shaping the stomach and promoting a distal dilation, treating downstream obstruction.
      • Baretta G.
      • Campos J.
      • Correia S.
      • et al.
      Bariatric postoperative fistula: a life-saving endoscopic procedure.
      • van Wezenbeek M.R.
      • de Milliano M.M.
      • Nienhuijs S.W.
      • et al.
      A specifically designed stent for anastomotic leaks after bariatric surgery: experiences in a tertiary referral hospital.
      The overall success rate of stent use was 72.8%, with a migration rate of 28.2%.
      • Okazaki O.
      • Bernardo W.M.
      • Brunaldi V.O.
      • et al.
      Efficacy and safety of stents in the treatment of fistula after bariatric surgery: a systematic review and meta-analysis.
      Recently, a newer stent, the megastent, has also emerged as an interesting option because its long and large shape adequately fits the tortuous anatomy of the SG, demonstrating superior results in comparison with esophageal stents in the management of sleeve leaks; however, serious adverse events may arise.
      • van Wezenbeek M.R.
      • de Milliano M.M.
      • Nienhuijs S.W.
      • et al.
      A specifically designed stent for anastomotic leaks after bariatric surgery: experiences in a tertiary referral hospital.
      • Galloro G.
      • Magno L.
      • Musella M.
      • et al.
      A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series.
      • Shehab H.
      • Abdallah E.
      • Gawdat K.
      • et al.
      Large bariatric-specific stents and over-the-scope clips in the management of post-bariatric surgery leaks.
      A 55-year-old morbidly obese woman underwent SG and experienced a gastric leak on the seventh postoperative day (Fig. 1). She was in clinically stable condition and was referred to our endoscopy unit for SEMS placement (Video 1, available online at www.VideoGIE.org). We opted for a fully covered bariatric megastent (28 mm × 24 cm), which completely occluded the leak at the proximal corpus (Fig. 2). Ten days later, the drain output increased and became darkish. An endoscopic reassessment identified a large perforation (Fig. 3) at the distal part of the esophagus where the proximal edge of the SEMS was anchored. The patient underwent emergency surgery. Intraoperatively, both the esophageal perforation (Fig. 4) and the gastric fistula (Fig. 5) were identified. We repaired both defects and placed mediastinal and peritoneal drains. Ten days later, we removed the stent and observed complete dehiscence of the esophageal perforation (Fig. 6) with a mediastinal drain into the orifice. We removed the drain from the orifice and placed the SEMS, with sponge system exchanges (Fig. 7) every 3 to 5 days. Nine vacuum system exchanges and 50 days were needed to completely close the esophageal perforation (Fig. 8). Moreover, treatment of the gastric leak entailed the removal of surgical staples and 2 septotomies (Fig. 9). Control endoscopy and upper GI series showed no signs of leaks. The patient was discharged 3 months after the SG with normal oral nutritional intake and was asymptomatic.
      Figure thumbnail gr1
      Figure 1Acute gastric leak identified during upper endoscopy.
      Figure thumbnail gr2
      Figure 2Bariatric stent occluding the leak.
      Figure thumbnail gr3
      Figure 3Larger perforation in distal esophagus identified during upper endoscopy.
      Figure thumbnail gr4
      Figure 4Gastric leak identified during surgery.
      Figure thumbnail gr5
      Figure 5Large esophageal perforation identified during surgery. SEMS, Self-expandable metal stent.
      Figure thumbnail gr6
      Figure 6Complete dehiscence of the esophageal perforation and the mediastinal drainage.
      Figure thumbnail gr8
      Figure 8Scar after esophageal closure with endoscopic vacuum therapy.
      Figure thumbnail gr9
      Figure 9Septotomy with needle-knife close to the leak in the proximal corpus.
      In conclusion, the megastent should be used with caution because it may carry serious adverse events. Endoscopic vacuum therapy is a noteworthy option to treat large esophageal perforations. Treatment of leaks may require multiple endoscopy sessions and a combination of different techniques.

      Disclosure

      Dr Eduardo G. H. de Moura is a consultant for Boston Scientific and Olympus. All other authors disclosed no financial relationships relevant to this publication.

      Supplementary data

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