Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis

doi:10.1016/j.gie.2011.09.010

Gastrointestinal Endoscopy

Volume 75, Issue 2, February 2012, Pages 287-293

https://doi.org/10.1016/j.gie.2011.09.010 Get rights and content

Background

Bariatric surgery leaks can result in significant morbidity and mortality. Endoscopic placement of self-expandable stents (SESs) is emerging as a less-invasive alternative to surgery for the treatment of leaks.

Objective

To evaluate the success of SESs in the treatment of bariatric surgery leaks.

Design

Studies using SESs in the management of bariatric surgery leaks were selected. Success of SES treatment was defined as radiographic evidence of leak closure after stent removal. Articles were searched in MEDLINE, PubMed, Ovid, and Cochrane Register of Controlled Trials. Pooled proportions were calculated by using fixed- and random-effects models. Publication bias was calculated by using the Begg-Mazumdar and Harbord bias estimators.

Results

A total of 189 relevant articles were reviewed of which 7 studies (67 patients with leaks) met inclusion criteria. The pooled proportion of successful leak closures by using SESs was 87.77% (95% CI, 79.39%-94.19%). The pooled proportion of successful endoscopic stent removal was 91.57% (95% CI, 84.22%-96.77%). Stent migration was noted in 16.94% (95% CI, 9.32%-26.27%). Test of heterogeneity gave a P value >.10. There was no publication bias.

Limitations

Small retrospective studies, different types of stents used.

Conclusion

Endoscopic placement of SESs is a minimally invasive, safe, and effective alternative in the management of leaks after bariatric surgery. The use of SESs can minimize the need for surgical revision and improve patient outcomes.

Section snippets

Methods

The systematic review and meta-analysis were written in accordance with the proposal for reporting by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.²² The study design for this meta-analysis and systematic review conformed to the guidelines of the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) study group.²³

Results

The initial search identified 1120 reference articles, in which 189 relevant articles were selected and reviewed. Data were extracted from 7 studies (67 patients with leaks) that met the inclusion criteria.15, 16, 17, 18, 19, 20, 21 Figure 1 and Table 1 show the search results and studies included in this meta-analysis. The agreement between reviewers for the collected data gave a Cohen κ value of 1.0.

This systematic review and meta-analysis included patients who underwent several types of

Discussion

The incidence of bariatric postoperative leaks ranged between 0.1% and 5.6%4, 6, 7, 9, 10, 11, 32, 33, 34, 35 and is considerably higher after revision surgery.10, 11, 36, 37 Several comorbid conditions have been associated with an increased risk of postoperative complications and may increase the likelihood of a leak developing. These risk factors include body mass index, diabetes mellitus, sleep apnea, and hypertension. In addition to these factors, age older than 55 years, male sex, and

Conclusion

Postoperative leaks after bariatric surgery can result in significant morbidity and mortality, especially in patients who require reoperation. The use of covered stents is emerging as a minimally invasive and relatively safe and effective treatment approach for leaks after bariatric surgery. SES placement can be considered in patients who are hemodynamically stable with adequate drainage and when reoperation is not necessary. The results of this systematic review and meta-analysis suggest that

References (38)

B.M. Yurcisin et al.
Obesity and bariatric surgery
Clin Chest Med
(2009)
R. Gonzalez et al.
Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity
J Am Coll Surg
(2007)
C.A. Edwards et al.
Management of anastomotic leaks after Roux-en-Y bypass using self-expanding polyester stents
Surg Obes Relat Dis
(2008)
B.F. Merrifield et al.
Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach
Gastrointest Endosc
(2006)
S. Eubanks et al.
Use of endoscopic stents to treat anastomotic complications after bariatric surgery
J Am Coll Surg
(2008)
R. Fukumoto et al.
Use of polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery
Surg Obes Relat Dis
(2007)
A. Salinas et al.
Self-expandable metal stents to treat gastric leaks
Surg Obes Relat Dis
(2006)
A.R. Jadad et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?
Control Clin Trials
(1996)
R. DerSimonian et al.
Meta-analysis in clinical trials
Control Clin Trials
(1986)
E.H. Livingston et al.
Assessing the relative contribution of individual risk factors on surgical outcome for gastric bypass surgery: a baseline probability analysis
J Surg Res
(2002)

J. Colquitt et al.

Surgery for morbid obesity

Cochrane Database Syst Rev

(2005)

H. Buchwald et al.

Bariatric surgery: a systematic review and meta-analysis

JAMA

(2004)

E.J. DeMaria

Bariatric surgery for morbid obesity

N Engl J Med

(2007)

Y.D. Podnos et al.

Complications after laparoscopic gastric bypass: a review of 3464 cases

Arch Surg

(2003)

J.S. Marshall et al.

Roux-en-Y gastric bypass leak complications

Arch Surg

(2003)

T. Almahmeed et al.

Morbidity of anastomotic leaks in patients undergoing Roux-en-Y gastric bypass

Arch Surg

(2007)

R. Gonzalez et al.

Anastomotic leaks after laparoscopic gastric bypass

Obes Surg

(2004)

A.Z. Fernandez et al.

Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality

Surg Endosc

(2004)

C. Ballesta et al.

Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass

Obes Surg

(2008)

Cited by (149)

Endoscopic management of surgical complications
2024, Best Practice and Research: Clinical Gastroenterology
While the endoscopic management of surgical complications like leaks, fistulas, and perforations is rapidly evolving, its core principles revolve around closure, drainage, and containment. Effectively managing these conditions relies on several factors, such as the underlying cause, chronicity of the lesion, tissue viability, co-morbidities, availability of devices, and expertise required to perform the endoscopy. In contrast to acute perforation, fistulas and leaks often demand a multimodal approach requiring more than one session to achieve the required results. Although the ultimate goal is complete resolution, these endoscopic interventions can provide clinical stability, enabling enteral feeding to lead to early hospital discharge or elective surgery. In this discussion, we emphasize the current state of knowledge and the prospective role of endoscopic interventions in managing surgical complications.
Clinical Efficacy and Safety of a Novel Stent for Fistula Management Following Sleeve Gastrectomy
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Management of fistulas after bariatric surgery has shifted from a surgical to a primarily endoscopic approach. We aimed to determine the efficacy of a novel stent for the closure of fistulas and stent-related adverse events in patients with fistulas after sleeve gastrectomy (SG).
Fifteen patients who developed fistulas following SG between July 2016 and December 2020 and managed at a tertiary care hospital by a primarily endoscopic approach were retrospectively evaluated. The technical and clinical success of a novel stent for the exclusion and definitive closure of fistulas and the need for endoscopic and surgical reinterventions and adverse events were analyzed.
Fifteen patients with median age of 47 (20-61) years, 11 (73%) females, were included. Fistulas were located at the cardia in 12 (80%) patients, with a median diameter of 4 (2-15) mm. Concomitant stricture of the gastric tube was detected in 8 (53%) patients. A single stent was placed in 13 (87%) patients. Endoscopic reinterventions were required in 5 (33%), and a surgical toilette was needed for 3 (20%) patients. After a median stent implantation duration of 6 (3-21) weeks, fistula closure was documented in all 15 (100%) patients. The concomitant stricture of the gastric tube that occurred in 8 (53%) patients was also successfully managed. Adverse events related to stent placement or removal occurred in 5 (33%) patients and were managed endoscopically. Stent dysfunction occurred in 1 (7%) patient. One patient died due to bleeding from an aortoesophageal fistula 3 cm above the proximal edge of the stent.
The novel stent is effective in closing fistulas after SG. The unique stent design is associated with a low risk of migration, allows for the management of concomitant strictures in the gastric tube, and facilitates stent removal.
Endoscopic management of bariatric complications
2022, Surgery (United Kingdom)
Bariatric metabolic surgery is a common elective general surgical procedure. Sleeve gastrectomy and Roux-en-Y gastric bypass are the two most common surgeries performed. They are considered safe with low morbidity and mortality. Leaks and bleeding are early complications after surgery. Endoscopy plays an important role in the diagnostic and therapeutic management of these complications. Advances in endoscopic interventions have increased the available options. It is important that healthcare professionals in non-specialized bariatric units who encounter these complications liaise with specialized units for advice and management.
Mesenchymal Stem Cells and Platelet Rich Plasma Therapy to Treat Leak After Sleeve Gastrectomy
2021, Journal of Surgical Research
Citation Excerpt :
The CT scans in both cases showed complete resolution of the fistula: 30 D for the first case and 42 D for the second. These results are very encouraging considering that a stent closes the fistula in a range of 41 D to 3.2 MO as found by Puli et al.13 Concerning the inflammatory markers, white blood cells normalized during the course of SCM-PRP injections.
One of the most feared and life-threatening complications after sleeve gastrectomy (SG) is staple line leak, with an incidence between 1 and 4%. Stable patients may be managed conservatively, with antibiotics, percutaneous drainage and endoscopy-based treatment. We propose mesenchymal stem cells (MSC) and platelet rich plasma (PRP) therapy as an innovative technique to treat leak after SG.
Bone marrow MSCs is obtained by centrifugation of tibial puncture specimen. A peripheral whole blood sample is retrieved from the patient and centrifuged to obtain PRP. During endoscopy, the first 10 mL are injected in 4quadrants (equal volume) in the submucosae around the internal orifice. The second 10 mL are injected in the wall of the fistula tract.
The immediate course following the endoscopy was uneventful in both reported cases. The leaks healed in 30 and 42 D, respectively. Oral nutrition was progressively started during the third WK and fourth WK following the injection for both patients. No adverse event was noted during the follow-up period.
The management of fistulas post SG is controversial and actual available treatments present a relatively prolonged healing time. MSC administration retains a high potential value in the treatment of these fistulas. Further studies and wider clinical trials are mandatory to determine the impact of MSC administration.
Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks
2021, Gastrointestinal Endoscopy
Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence.
This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and 2019.
Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy–related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%.
Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.
Comment on: Aortic injuries following stents in bariatric surgery: our experience
2021, Surgery for Obesity and Related Diseases

View all citing articles on Scopus

: DISCLOSURE: The following author disclosed financial relationships relevant to this publication: Dr. Thompson: consultant to Boston Scientific and Olympus. The other authors disclosed no financial relationships relevant to this publication.

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Original articleClinical endoscopyUse of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis

Background

Objective

Design

Results

Limitations

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Clin Chest Med

J Am Coll Surg

Surg Obes Relat Dis

Gastrointest Endosc

J Am Coll Surg

Surg Obes Relat Dis

Surg Obes Relat Dis

Control Clin Trials

Control Clin Trials

J Surg Res

Surgery for morbid obesity

Cochrane Database Syst Rev

Bariatric surgery: a systematic review and meta-analysis

JAMA

Bariatric surgery for morbid obesity

N Engl J Med

Complications after laparoscopic gastric bypass: a review of 3464 cases

Arch Surg

Roux-en-Y gastric bypass leak complications

Arch Surg

Morbidity of anastomotic leaks in patients undergoing Roux-en-Y gastric bypass

Arch Surg

Anastomotic leaks after laparoscopic gastric bypass

Obes Surg

Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality

Surg Endosc

Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass

Obes Surg

Original article
Clinical endoscopy
Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis