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Endoscopic rescue of anastomotic dehiscence after urgent gastric bypass revision

Open AccessPublished:September 28, 2022DOI:https://doi.org/10.1016/j.vgie.2022.07.013

      Video

      (mp4, (116.49 MB)

      Abbreviation:

      eVAC (endoluminal vacuum therapy)

      Introduction

      Adverse events are rare after bariatric surgery; however, leaks can lead to high morbidity. A large population study demonstrated a rare need for endoscopic management, most commonly endoluminal stent therapy. Unfortunately, many patients eventually needed surgical intervention and patients with stents had a notable rate of readmissions.
      • Kanters A.E.
      • Shubeck S.P.
      • Varban O.A.
      • et al.
      Incidence and efficacy of stent placement in leak management after bariatric surgery: an MBSAQIP analysis.
      Although stents are a valuable tool, newer technologies have expanded the toolbox to address difficult gastrointestinal adverse events.
      • Ge P.S.
      • Thompson C.C.
      The use of the OverStitch to close perforations and fistulas.
      ,
      • Popoutchi P.
      • Costa Mendes M.M.
      • Averbach P.
      • et al.
      Endoluminal vacuum therapy for the treatment of complete dehiscence of low colorectal anastomosis.
      We present a challenging case of a gastrojejunal anastomotic disruption in a Roux-en-Y patient after recent urgent surgical revision that was rescued with total endoscopic therapy.

      Case Report

      A 79-year-old individual with previous vertical banded gastroplasty converted to a Roux-en-Y was hospitalized for recurrent marginal ulcer bleeding. Endoscopic management failed after 2 attempts. They underwent urgent surgical revision of the gastrojejunal anastomosis. Rising leukocytosis was noted 8 days later. A CT scan demonstrated featured concerns for anastomotic leak (Fig. 1). Urgent endoscopy demonstrated a near total anastomotic dehiscence with large separation of the bowel and abscess cavity (Fig. 2). The abscess cavity was washed out, and the decision was made to use endoluminal vacuum therapy (eVAC) to debride the abscess and manage the leak (Fig. 3).
      Figure thumbnail gr1
      Figure 1Initial CT scan of the abdomen demonstrating extraluminal air both to the left (A) and anterior (B) of the gastrojejunal anastomosis, consistent with a leak.
      Figure thumbnail gr2
      Figure 2Initial endoscopic session where a near total anastomotic disruption was found (A) in addition to a large left-posterior abscess cavity (B).
      Figure thumbnail gr3
      Figure 3Endoluminal vacuum therapy applied to manage the contaminated abscess cavity.
      Endoscopy 4 days later revealed an infection-free cavity, although the patient exhibited persistent dehiscence. Endoscopic suturing was used to reapproximate the anterior 180 degrees of the anastomosis (Fig. 4). Given the large cavity, eVAC therapy was resumed to control the abscess. To avoid prolonged eVAC therapy requiring hospitalization, a percutaneous drain was placed allowing the remaining posterior dehiscence to be endoscopically sutured together, thus rescuing the near-total anastomotic dehiscence. To buttress the repair, a covered esophageal stent was deployed across the anastomosis and a nasojejunal feeding tube was placed to allow for enteric feeds (Fig. 5). We were then able to discharge the patient to rehabilitation.
      Figure thumbnail gr4
      Figure 4Endoscopic suturing to reapproximate the anastomotic disruption. The suture pattern was taken from the jejunum (A) to the gastric pouch (B) starting on the anterior aspect first (A, B), and then on the posterior aspect of the anastomosis (C). The final suture cinch deployed after reapproximation (D).
      Figure thumbnail gr5
      Figure 5Reinforcement of the suture reapproximation with an endoluminal stent. Through the stent, a nasojejunal feeding tube was clipped down the roux limb for enteral feeds.
      Later in clinic, the patient was tolerating full liquids, and thus the feeding tube was removed. On repeat endoscopy 20 days later, the stent was removed revealing an intact gastrojejunal anastomosis (Fig. 6). On-the-table fluoroscopy confirmed no ongoing leakage. The patient returned home, advanced to a solid diet, and was doing well on subsequent follow-up.
      Figure thumbnail gr6
      Figure 6Final endoscopic appearance after total rescue of the anastomotic disruption.

      Discussion

      As more weight loss surgeries are being performed, a notable volume of rare adverse events may happen. Traditional methods of managing events after bariatric surgery often require morbid return trips to the operating room. Endoscopic therapy offers tools and techniques to address surgical issues in a noninvasive fashion (Table 1) Traditionally, stent therapy has been used to manage anastomotic leaks.
      • Kanters A.E.
      • Shubeck S.P.
      • Varban O.A.
      • et al.
      Incidence and efficacy of stent placement in leak management after bariatric surgery: an MBSAQIP analysis.
      However, stent therapy can lead to its own host of issues from stent migration to debilitating reflux and chest and abdominal pain. Furthermore, use of stent therapy requires multiple return trips for removal and replacement as the tissue heals. It is the opinion of the authors that stent therapy does not actually promote healing. The radial force of stents theoretically put tension on the outlying tissue that may compromise capillary blood flow. Stents are merely a conduit for diverting GI contents away from a leak.
      Table 1List of devices used and their manufacturers
      DeviceGeneric nameTrade nameManufacturerCityState
      Upper EndoscopeTherapeutic GastroscopeGIF-2T180OlympusCenter ValleyPennsylvania
      SutureOverStitchOverStitchApollo EndosurgeryAustinTexas
      Esophageal StentStentEndoMaxMerit MedicalJordanUtah
      SpongeWound VacNegative Pressure Therapy3M KCISan AntonioTexas
      Novel endoscopic therapies have allowed for a more surgical technique to be applied through endoscopy. eVAC therapy allows for debridement and wound healing. Endoscopic suturing is a game-changer and has revolutionized the ability to perform endoscopic tissue approximation. Using these techniques, we demonstrate the successful rescue of a near total anastomotic disruption after urgent gastric bypass revision, obviating the need for a morbid surgical procedure (Video 1, available online at www.giejournal.org).

      Disclosure

      All authors disclosed no financial relationships.

      Supplementary data

      References

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        • Shubeck S.P.
        • Varban O.A.
        • et al.
        Incidence and efficacy of stent placement in leak management after bariatric surgery: an MBSAQIP analysis.
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        • Ge P.S.
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        Endoluminal vacuum therapy for the treatment of complete dehiscence of low colorectal anastomosis.
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