Camila B. Ortega

Endoscopic Abscess Septotomy for Management of Sleeve Gastrectomy Leak

Surgical management continues to be the most effective treatment for morbid obesity. Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric intervention performed worldwide [1] based on significant weight loss outcomes, improvement of comorbidities [2], and its association with low morbidity and mortality rates [3]. Although very effective, LSG is not exempt of complications. One of the major concerns is the development of a staple line leakage. Even though, the incidence of this complication is low (ranging from 1 to 6%), postoperative leaks represent a devastating condition for the patient often resulting in prolonged hospitalization, sepsis, and even death [4, 5]. The management of post-LSG leaks is aimed at defining the leak and controlling potential fluid collection and abscess formation through non-surgical and/or surgical interventions [6]. Endoscopy plays a valuable role for this purpose [7]. The use of stents placed endoscopically is the most popular treatment [5]. However, recent studies have reported variable outcomes in terms of efficacy [8–10] and complication rates [11]. Management algorithms have been developed by a few centers with the purpose of standardizing the treatment. As such, Nedelcu et al. [11] recommended an algorithm depending on the size of the fistula; Nimeri et al. [12] developed another algorithm based on the time of presentation of the leak, the presence of distal stomach stricture, nutritional status, and the presence of peritonitis. Both studies applied endoscopic approaches using stents, pigtail catheters, or clips for the treatment. Other studies reported the successful use of the over-the-scope clip (OTSC) system for the management of early leaks [13, 14]. Lastly, when all endoscopic treatments failed, surgical re-intervention to converting the gastric sleeve to a Roux-en-Y gastric bypass or a total gastrectomy has also been described [11, 15]. An abscess septotomy is a technique in which the septum separating the abscess cavity and the gastric lumen is incised and divided (Fig. 1) resulting in the complete exposure of the lumen of both cavities. By these means, redirection of the leak flow from the abscess cavity towards the gastric lumen favors the internal drainage and suppresses the accumulation of contents contributing to the abscess formation, therefore decreasing the expansion of the collection and providing tissue healing. This represents a feasible approach that has been studied and described for the past years by authors reporting good outcomes in terms of clinical and radiologic resolution of the leak. De Lima [16] shared his experience of ten cases of post-LSG early leaks, stating resolution of the complication, in addition to a reduction in the duration of hospital stay and need for reintervention. Additionally, studies reporting endoscopic septotomy in conjunction with pneumatic balloon dilation for the management of sleeve strictures [7, 17] concluded that addressing the distal stenosis of the sleeve results in decreased intraluminal pressure, hence favoring tissue healing. In conclusion, based on published case series, endoscopic abscess septotomy offers a less invasive, safe, and effective alternative for the management of postoperative LSG leaks. The adoption of this technique reduces the need for additional surgical intervention. * Alfredo D. Guerron daniel.guerron@duke.edu

Asthma medication usage is significantly reduced following bariatric surgery

IntroductionAsthma is an important healthcare problem affecting millions in the United States. Additionally, a large proportion of patients with asthma suffer from obesity. These patients exhibit poor asthma control and reduced therapy response, increasing utilization of healthcare resources. Pulmonary symptoms improve after bariatric surgery (BS), and we hypothesized that asthma medication usage would decrease following BS.MethodsA retrospective data analysis was performed in adult patients from a single institution’s database. Patients with obesity using at least one asthma medication pre-operatively who underwent BS were studied for up to 3-years post-operation. Poisson generalized linear mixed models for repeated measures were used to evaluate the effects of time and procedure type on the number of asthma medication.ResultsBariatric patients with at least one prescribed asthma medication (mean 1.4u2009±u20090.6) were included (nu2009=u2009751). The mean age at time of operation was 46.8u2009±u200911.6xa0years, mean weight was 295.9u2009±u200957xa0lbs, and mean body mass index (BMI) was 49u2009±u20098.2xa0kg/m2; 87.7% were female, 33.4% had diabetes, 44.2% used gastroesophageal reflux disease (GERD) medication, and 64.4% used hypertension medication. The most common procedure was Roux-en-Y gastric bypass (79%), followed by sleeve gastrectomy (10.7%), adjustable gastric banding (8.1%), and duodenal switch (2.3%). The mean number of prescribed asthma medications among all procedures decreased by 27% at 30xa0days post-operation (pu2009<u20090.0001), 37% at 6xa0months (pu2009<u20090.0001), 44% at 1xa0year (pu2009<u20090.0001), and 46% at 3xa0years (pu2009<u20090.0001) after adjusting for risk factors. No significant differences in medication use over time between procedure types were observed. In the adjusted analysis, the mean number of asthma medications was 12% higher in patients using at least one GERD medication (pu2009=u20090.015) and 8% higher with 10-unit increase in pre-operative BMI (pu2009=u20090.006).ConclusionBS significantly decreases asthma medication use starting 30xa0days post-operation with a sustained reduction for up to 3xa0years.

Anastomotic Leak Following Gastric Bypass

Anastomotic leak represents a serious complication of gastric bypass carrying significant morbidity and mortality for the bariatric patient, frequently leading to prolonged hospital stay, additional diagnostic tests, and increased risk for surgical reintervention. Leaks may develop in approximately 5% of patients following gastric bypass as a result of mechanical and/or ischemic factors disrupting the normal healing process of a suture or staple line. This chapter describes the classification and clinical presentation of leaks, as well as the key features for prevention, early diagnosis, and management. Bariatric surgery is an effective therapeutic option for morbid obesity. The prompt identification and management of its related complications are essential to improving clinical practice and surgical outcomes.