Endoscopic management of refractory leaks and fistulas after bariatric surgery with long-term follow-up

Abstract

Background

In selected cases of post-bariatric leaks and fistulas, endoscopy is an initial treatment modality. Management can be complex and require multiple endoscopic sessions with varying degrees of success. Our aim was to describe our tertiary care experience on endoscopy management of refractory post-bariatric leaks and fistulas.

Methods

Patients with post-bariatric leaks and/or fistulas who failed an initial endoscopic intervention were included. Endoscopic treatments were classified into four strategies: (1) closure management, (2) active drainage, (3) passive drainage, and (4) plugging. Clinical success and adverse events were assessed.

Results

A total of 25 patients (mean age = 45.3 ± 11.8 years and 56% female) were included. Clinical success was achieved in 20 patients (80%) with a mean of 3.0 ± 1.5 procedures and a median time to healing of 114.5 (53–210.3) days. Closure and plugging were the main successful strategies used for early and acute leaks/fistulas, while drainage was for late and chronic leaks/fistulas. Adverse events were observed in 13 patients (52%) with one serious adverse event. Patients with fistulas had a lower success rate (72.2% vs. 100%, P = 0.052). Of those with clinical failure (n = 5), four underwent reconstructive surgery, eventually led to success in 3 patients. The other one died of septic shock related to a complicated fistula.

Conclusions

Complex multi-modality endoscopic management ultimately achieved clinical success in most cases of refractory leaks/fistulas post-bariatric with an acceptable safety profile. However, a close follow-up to detect the development of long-term failure is warranted. These patients should be referred to a specialized bariatric center with expertise in bariatric endoscopy and surgery.

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Authors

Contributions

BA conceived and designed the study and critically revised the manuscript. VJ and EV designed the study, collected, analyzed, and interpreted the data and drafted the manuscript. DM and RM collected the data and drafted the manuscript. ACS interpreted the data, drafted, and critically revised the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Barham K. Abu Dayyeh.

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Conflict of interests

Dr. Abu Dayyeh is a consultant for Metamodix, BFKW, DyaMx, Boston Scientific, USGI medical, and Endo-TAGSS. He received research support from Apollo Endosurgery, USGI, Spatz Medical, Boston Scientific, GI Dynamics, Cairn Diagnostics, Aspire Bariatrics, and Medtronic. He served as a speaker for Johnson and Johnson, Endogastric Solutions, and Olympus. Dr. Storm is a consultant for Apollo Endosurgery, ERBE, GI Dynamics, and Endo-TAGSS. He received research support from Boston Scientific and Apollo Endosurgery. Dr. Jaruvongvanich, Reem Matar, Dr. Azilzullah, Dr. Malandris, Dr. Maselli, Dr. Vargas, Dr. Kellogg, Dr. Buttar, and Dr. McKenzie have no financial disclosures or conflicts of interest relevant to this study.

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Our study was approved by the Ethics Committee of the Mayo Clinic Rochester.

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Jaruvongvanich, V., Matar, R., Storm, A.C. et al. Endoscopic management of refractory leaks and fistulas after bariatric surgery with long-term follow-up. Surg Endosc (2020). https://doi.org/10.1007/s00464-020-07702-5

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Keywords

  • Bariatric surgery
  • Fistula
  • Leaks
  • Roux-en-Y gastric bypass
  • Sleeve gastrectomy