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Management of a refractory leak after sleeve gastrectomy: the endoscopic armamentarium

Open AccessPublished:May 25, 2019DOI:https://doi.org/10.1016/j.vgie.2019.04.006

      Abbreviation:

      APC (argon plasma coagulation)
      Leaks after sleeve gastrectomy are serious postoperative adverse events with significant morbidity. The timing of presentation and the chronicity of the leak affect management strategy, with acute/early (<6 weeks) leaks typically treated differently from late/chronic (>6-12 weeks) leaks.
      • Christophorou D.
      • Valats J.C.
      • Funakoshi N.
      • et al.
      Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study.
      • Mahadev S.
      • Kumbhari V.
      • Campos J.M.
      • et al.
      Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections.
      Ultimately, once a leak has matured and contains a fibrous septum, a septotomy may be necessary for definitive treatment. We present our approach to a refractory gastric sleeve leak managed with various endoscopic modalities.
      A 48-year-old woman was transferred to our hospital 2 weeks after sleeve gastrectomy with fever, tachycardia, and hypotension. She was found to have pneumoperitoneum and underwent an exploratory laparotomy with the concomitant placement of percutaneous drains into an abscess cavity. Follow-up imaging demonstrated a large-volume leak from the proximal aspect of her gastric sleeve (Fig. 1A and B). Upper endoscopy confirmed a 3-cm defect along the proximal staple line in communication with a perigastric abscess cavity (Fig. 2; Video 1, available online at www.VideoGIE.org). Severe stenosis of the distal lumen was also noted. Given the thick tenacious material within the leak cavity, which did not readily pass through the percutaneous drains, the decision was made to place 10F × 3-cm double-pigtail stents to provide internal drainage of the cavity through the gastric lumen. Pneumatic dilation with a 30-mm diameter balloon to 20 pounds per square inch was also performed distal to the leak site to decrease the pressure gradient and promote healing.
      Figure thumbnail gr1
      Figure 1A, CT scan demonstrating perigastric fluid collection. B, Upper-GI series demonstrating leak from the proximal aspect of the gastric sleeve.
      Figure thumbnail gr2
      Figure 2Initial endoscopy revealing a 3-cm defect at the proximal staple line.
      Despite these interventions, the leak persisted with ongoing drainage through the laparotomy incision, resulting in skin breakdown at the abdominal wall. Repeated endoscopy 6 weeks after the index surgery was performed, at which point the abscess cavity was debrided and a covered self-expandable metal stent was placed. Twelve weeks after the index surgery, the stent was removed, and a chronic fibrous septum was found (Fig. 3). Owing to the patient’s inability to tolerate oral intake, the decision was made to perform a septotomy.
      Figure thumbnail gr3
      Figure 3Repeated endoscopy demonstrating a fibrous septum separating the leak cavity and the gastric lumen that extended 3 cm distally.
      The septotomy was performed with an insulated cutting knife (Fig. 4). The septum was divided, with care being taken to avoid injury to the leak cavity wall. Foreign material was removed to promote healing, and bleeding was treated with the insulated cutting knife and argon plasma coagulation (APC).
      Figure thumbnail gr4
      Figure 4Septotomy with an insulated cutting knife.
      The patient was discharged the following day. Subsequent imaging demonstrated resolution of her fluid collection (Fig. 5). She was able to advance her diet without further symptoms.
      Figure thumbnail gr5
      Figure 5Follow-up CT scan demonstrating resolution of the perigastric collection and leak.
      Sleeve gastrectomy has rapidly become a popular bariatric surgery option, representing 59% of all bariatric procedures performed in the United States in 2017.
      Estimate of Bariatric Surgery Numbers, 2011-2017.
      Although this procedure is less morbid than other bariatric surgery options, staple line leaks are estimated to occur in 1% to 7% of patients after sleeve gastrectomy.
      • Mahadev S.
      • Kumbhari V.
      • Campos J.M.
      • et al.
      Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections.
      The proposed mechanism includes mechanical disruption of the staple line, relative ischemia resulting from the takedown of the short gastric arteries, and increased intraluminal pressure.
      • Kumbhari V.
      • Cai J.X.
      • Schweitzer M.A.
      Endoscopic management of bariatric surgical complications.
      Simultaneous distal sleeve stenosis may be present.
      • Kumbhari V.
      • Cai J.X.
      • Schweitzer M.A.
      Endoscopic management of bariatric surgical complications.
      Septotomy with needle-knife, APC, or both has been reported for the successful treatment of late or chronic leaks to completely expose the lumen of the leak cavity and to equalize pressures between the gastric lumen and perigastric collection.
      • Mahadev S.
      • Kumbhari V.
      • Campos J.M.
      • et al.
      Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections.
      • Ortega C.B.
      • Guerron A.D.
      • Portenier D.
      Endoscopic abscess septotomy: a less invasive approach for the treatment of sleeve gastrectomy leaks.
      • Campos J.M.
      • Ferreira F.C.
      • Teixeira A.F.
      • et al.
      Septotomy and balloon dilation to treat chronic leak after sleeve gastrectomy: technical principles.
      • 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.
      Available published reports have described a mean of 2.3 to 5 septotomy procedures to completely divide the septum.
      • Mahadev S.
      • Kumbhari V.
      • Campos J.M.
      • et al.
      Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections.
      • 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.
      The current case demonstrates the novel use of an insulated cutting knife with APC to safely perform the septotomy in a single session. Removal of foreign body material and pneumatic dilation of the distal sleeve remain important adjunctive strategies for the successful endoscopic management of chronic sleeve leaks.

      Disclosure

      Dr Schulman is a consultant for Apollo Endosurgery, Boston Scientific, and Microtech. The other author disclosed no financial relationships relevant to this publication.

      Supplementary data

      References

        • Christophorou D.
        • Valats J.C.
        • Funakoshi N.
        • et al.
        Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study.
        Endoscopy. 2015; 47: 988-996
        • Mahadev S.
        • Kumbhari V.
        • Campos J.M.
        • et al.
        Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections.
        Endoscopy. 2017; 49: 504-508
      1. Estimate of Bariatric Surgery Numbers, 2011-2017.
        ASMBS Professional Resource Center. Volume 2019. ASMBS, Gainesville, FL2018
        • Kumbhari V.
        • Cai J.X.
        • Schweitzer M.A.
        Endoscopic management of bariatric surgical complications.
        Curr Opin Gastroenterol. 2015; 31: 359-367
        • Ortega C.B.
        • Guerron A.D.
        • Portenier D.
        Endoscopic abscess septotomy: a less invasive approach for the treatment of sleeve gastrectomy leaks.
        J Laparoendosc Adv Surg Tech A. 2018; 28: 859-863
        • Campos J.M.
        • Ferreira F.C.
        • Teixeira A.F.
        • et al.
        Septotomy and balloon dilation to treat chronic leak after sleeve gastrectomy: technical principles.
        Obes Surg. 2016; 26: 1992-1993
        • 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