Nicole Fearing

Use of Endoscopic Stents to Treat Anastomotic Complications after Bariatric Surgery

BACKGROUND Complications after bariatric surgery often require longterm parenteral nutrition to achieve healing. Recently, endoscopic treatments have become available that provide healing while allowing for oral nutrition. The purpose of this study was to present outcomes of the largest series to date treating staple line complications after bariatric surgery with endoscopic covered stents. STUDY DESIGN A retrospective evaluation was performed of all patients treated for staple line complications after bariatric surgery at a single tertiary care bariatric center. Acute postoperative leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after both gastric bypass and sleeve gastrectomy were included. RESULTS From January 2006 to June 2007, 19 patients (11 with acute leaks, 2 with chronic fistulas, and 6 with strictures) were treated with a total of 34 endoscopic silicone covered stents (23 polyester, 11 metal). Mean followup was 3.6 months. Immediate symptomatic improvement occurred in 90% (91% of acute leaks, 100% of fistulas, and 84% of strictures). Oral feeding was started in 79% of patients immediately after stenting. Resolution of leak or stricture after stent treatment occurred in 16 of 19 patients (84%). Healing of leak, fistula, and stricture occurred at means of 33 days, 46 days, and 7 days, respectively. Three patients (1 with leak, 1 with fistula, and 1 with stricture) had unsuccessful stent treatment. Migration of the stent occurred in 58% of 34 stents placed. Most migration was minimal, but three stents were removed surgically after distal small bowel migration. There was no mortality. CONCLUSIONS Treatment of anastomotic complications after bariatric surgery with endoscopic covered stents allows rapid healing while simultaneously allowing for oral nutrition. The primary morbidity is stent migration.

Management of anastomotic leaks after Roux-en-Y bypass using self-expanding polyester stents

BACKGROUND To analyze the outcomes of a series of endoscopically placed polyester self-expanding polyflex stents (SEPSs) for the management of anastomotic leaks after Roux-en-Y bypass. Anastomotic leaks after gastric bypass cause significant morbidity and mortality. Covered polyester SEPSs might have a role in the treatment of these leaks. METHODS A retrospective chart review was performed from January 2006 to November 2006 that included all acute and chronic leaks treated with SEPSs. RESULTS A total of 6 patients were treated with stents, with a mean procedure time of 22 minutes. Of these 6 patients, 5 had acute postoperative leaks and 1 had a chronic fistula. Five patients started oral intake 1-6 days after their procedure. All acute leaks had complete healing at a median of 44 days. The patient with a chronic gastrocutaneous fistula required revisional surgery for fistula closure. In addition, 5 patients had stent migration, and 3 required stent replacement. CONCLUSION An endoscopically placed SEPS provides a less-invasive alternative to treat acute anastomotic leaks after Roux-en-Y bypass while simultaneously allowing oral intake. The results of this case series have demonstrated this treatment to be safe and effective.

Long-term outcome after endoscopic stent therapy for complications after bariatric surgery

Although bariatric surgery effectively reduces the mortality risk from obesity-related comorbidities [1, 2], it is associated with a 1–5% risk of anastomotic complications. Anastomotic leaks have traditionally been treated with a combination of drainage with long-term parenteral nutrition or postanastomotic enteral nutrition, allowing the leak to heal. Strictures at the gastrojejunostomy are initially treated with repeated endoscopic dilation, but revisional bariatric surgery is needed for refractory strictures with its associated high complication rate. Chronic fistulas are initially treated conservatively but often need high-risk revisional surgery. Recently, endoscopic covered stents have been used successfully for treatment of anastomotic complications after esophageal resection [3–5]. Case series evaluating stents to treat anastomotic leaks after Roux-enY gastric bypass have shown success [6–9]. However, the numbers of patients enrolled in these studies are small, and only short-term outcomes are reported. The primary aim of this study is to present long-term healing rates after endoscopically placed covered stents in the treatment of various anastomotic complications after bariatric surgery. The secondary aim is to analyze symptom improvement scores, complications, and factors affecting stent migration.

Laparoscopic Repair of Perforated Marginal Ulcer Following Roux-en-Y Gastric Bypass: A Case Series

INTRODUCTION Marginal ulcer perforation is a known complication of Roux-en-Y gastric bypass (RYGB), and laparoscopic repair may be a feasible option minimizing the morbidity associated with a large laparotomy incision. We present our experience with laparoscopic repair of perforated marginal ulcers in patients who have previously undergone RYGB. METHODS A retrospective chart review from August 2005 to April 2007 was performed identifying all patients who underwent laparoscopic repair of perforated marginal ulcer after RYGB at one hospital. The perforation was repaired either by laparoscopic primary suture closure followed by application of an omental patch or by laparoscopic Graham patch without primary suture repair. Operative time, duration of hospitalization, postoperative follow-up, and postoperative complications were recorded. Data are presented as mean ± standard deviation. RESULTS Six patients underwent laparoscopic repair of a perforated marginal ulcer. Operative time was 101.8 ± 50 minutes with a mean hospitalization of 5.3 ± 2.7 days. Follow-up was 6.2 ± 7.5 months. Postoperative complications included 2 patients with nausea and vomiting related to an exposed suture at the gastrojejunostomy, 1 patient with chronic gastritis, and 1 patient developed a stricture at the gastrojejunostomy. CONCLUSIONS We present the largest series to date of laparoscopic repair of perforated marginal ulcers utilizing an omental patch for repair. We demonstrate that a laparoscopic repair can be completed in a reasonable operative time, with minimal postoperative hospitalization, and low associated morbidity. Patients who develop a perforated marginal ulcer after RYGB can be safely and effectively treated with laparoscopic repair with an omental patch.