Stent-Over-Sponge as a rescue technique for leak post-bariatric surgery

The Stent-Over-Sponge (SOS) technique is safe and efficacious in dealing with post-operative leaks in patients having undergone bariatric surgery, according to a case report by researchers from the Hôpital du Sacré-Coeur, Canada. The case report, published in Cureus, presents the case of a 60-year-old female patient who underwent revisional bariatric surgery and developed a post-operation leak. To the researchers' knowledge, there are no other case reports of SOS in revisional bariatric surgery so far.

The patient presented with a history of gastric banding and subsequent sleeve gastrectomies and then Roux-en-Y gastric bypass. After the sleeve gastrectomy, she developed reflux symptoms, for which she underwent gastric bypass. After the bypass, she developed a small bowel fistula which was explored and a lot of adhesions were found, which were converted to laparotomy. On post-operative day four, the patient became septic. An abdominal computed tomography (CT) scan showed a large contrast leak near the gastro-jejunal anastomosis, with multiple intra-abdominal abscesses, for which four pigtails were inserted.

Figure 1: Photos from the upper endoscopy: Jackson-Pratt intrabdominal drain is seen by endoscopy, Endo-VAC insertion, and partially covered stent in place. (A) Intraperitoneal abdominal drain seen while doing endoscopy; (B) Cavity was reached by endoscopy and the pus was evacuated and the sponge was applied; (C) Placing the stent

Diagnostic upper endoscopy (Figure 1) was performed under general anaesthesia; it revealed complete dehiscence of the terminal staple line of the candy cane. An initial endoscopic debridement of the cavity was performed. Given the location and the large size of the leak, an Endo-VAC system on a 16F NGT was inserted. Due to angulation issues, an intra-cavitary placement was impossible, and the sponge was left within the Candy cane in an endoluminal position. Migration of the sponge into the alimentary limb was noted following two Endo-VAC changes.

Stent and Endo-VAC removal were performed urgently ten days after stent placement, as she developed significant hematemesis due to the patient attempting to remove the Endo-VAC herself. There was technical difficulty due to angulation issues related to the anastomosis type. Thus, putting the sponge in the cavity of the leakage defect was impossible, and the sponge was put endoluminal. Sponge migration was detected by follow-up endoscopy therefore, the SOS system was assembled using a partially covered stent with an Endo-VAC system.

Therefore, a partially covered esophageal stent (WallFlex 23mm*155mm, Boston Scientific) was placed with its distal end on the shared wall between the Candy cane and the alimentary limb to keep the Endo-VAC from migrating. Percutaneous drainage with four pigtails of the multiple intra-abdominal collections was performed with the endoscopic treatment. The SOS system prevented the migration of sponges, and the healing process improved. Complete leak closure was noted during the endoscopic control with clips of a small jejunal artery.

The researchers report that the patient is currently asymptomatic six months after the leak resolution, with complete resolution of the abdominal accesses.

“Combining the two methods is a promising technique. SOS is a new modality used as a rescue option,” they researchers concluded. “Further studies are needed to investigate this further.”

The findings were reported in the paper, ‘Stent-Over-Sponge (SOS) as a Rescue Technique for Leak Post-Bariatric Surgery: Experience From Hôpital du Sacré-Coeur, Canada’, published in Cureus. To access this paper, please click here