Endoscopic treatment of LOAGB complications - Anastomosis-related complications were more “amenable” to endoscopic treatment, compared to staple line leaks
Endoscopic treatment of laparoscopic one anastomosis gastric bypass complications (LOAGB) complications are effective and relatively safe, according to researchers from Tel Aviv University and Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. The study authors noted that anastomosis-related complications were more “amenable” to endoscopic treatment, compared to staple line leaks.
The retrospective study, ‘Endoscopic treatment of early leaks and strictures after laparoscopic one anastomosis gastric bypass’, published in BMC Surgery, summarised the experience from a single centre in treating post LOAGB complications such as leaks and strictures with endoscopic treatment.
In total, 17 patients were included in the study, nine with postoperative leaks and eight with post-operative strictures. Six patients (67%) had revisions from previous bariatric surgery including laparoscopic adjustable gastric banding (LAGB), silastic ring vertical gastroplasty (SRVG) and laparoscopic sleeve gastrectomy, three of which had two previous operations.
Eight patients (89%) had an early leak (1–6 week) and one had an (11%) acute leak (< 1 week). Five patients (56%) presented with a proximal staple-line leak (at the angle of His), three (33%) with an anastomotic leak and one patient (11%) had leaks at both sites. Median time between surgery and first endoscopy was 12 days (10–19) and the median number of therapeutic endoscopic sessions was three (2–6). All patients were treated with fully covered stents for a median period of 26 days (11–30).
Additional endoscopic treatment was required in four patients (45%), three required ancillary dilation. Two patients with staple line leak evolved to late fistula and needed additional drainage procedures including septotomy, double pigtail stent insertion and tissue glue.
Five of nine patients (56%) were successfully treated as defined by weaning from total parenteral nutrition, resuming oral diet, removal of intra-abdominal draining tubes, and avoidance of further surgical intervention with a follow up of approximately six months. All three patients with anastomotic leak had a favourable outcome, but only one of five patients with staple line leak had a favourable outcome. Of note, the patient with both anastomotic- and staple line-leaks recovered.
Two patients had a Roux-en-Y- gastric bypass (RYGB) conversion. One patient died due to respiratory failure secondary to severe pneumonia probably not related to the endoscopic procedure. Three of four 4failed patients (75%) had previous bariatric surgery.
Postoperative stricture group
Of the eight patients who were diagnosed with stricture based upon symptoms of vomiting and excessive weight loss, four patients (50%) had previous bariatric surgery including LAGB and LSG. Seven patients (88%) presented with anastomotic stricture and one patient (12.5%) with a mid-pouch kink. The median time between surgery and the first endoscopic dilation was 63 days (37–140), and the median number of therapeutic endoscopic dilation was 3 (2–4). All seven patients with anastomotic stricture reported significant clinical improvement with a follow up of six months after the last procedure. The patient with the pouch kink was defined as a treatment failure due to persistent vomiting and weight loss after three attempts of pneumatic dilation and had a RYGB conversion.
“The safety profile of endoscopic treatment could be further improved. Overall, we had two major complications. One case of stent migration resulted in small bowel perforation which necessitated urgent laparotomy. One death occurred, however it was not related to the endoscopic procedure,” the authors cautioned. “…Multicentric trials, with greater sample sizes are necessary.”
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