Endoscopy offers a less invasive approach and helps to treat many of the complications from bariatric surgery, according to Dr Matthew Kroh, Director of Surgical Endoscopy and Assistant Professor of Surgery at the Cleveland Clinic Lerner College of Medicine.
In a wide-ranging presentation at the Minimally Invasive Surgery Symposium, in Red Rock, Nevada, Kroh discussed how endoscopic techniques and the latest advances in endoscopic technology are assisting bariatric surgeons to ameliorate complications such as strictures and leakages, whilst still allowing them to adhere to their surgical principles.
“The rate of complications such as leaks and strictures after bariatric surgery remains significant.” And specifically, “the type of stricture is unique to the type of operation performed,” said Kroh. “Strictures are most common in bypass procedures, ranging from 3-22%, although they also occur in sleeve gastrectomy as well in the form of stenosis. Therefore, as surgeons we need to adopt a more tailored approach” to interventions
Strictures can manifest acutely after an operation or even years after surgery. The causes vary significantly and therefore to treat them, it is important to understand their aetiology. For example, acute (early) strictures may result from technical errors or ischemia, whereas long-term strictures are the result of chronic processes such as ulceration from NSAID use and smoking, or foreign body presence.
Kroh said that endoscopic specialists have several technologies to treat strictures including Through The Scope (TTS) Circumferentially Radially Expanding (CRE) balloons as well as Savary dilators to open chronic or long-segment strictures.
“The response rates of treating early strictures have been reported up to 90%,” he said. “However, they are not without complication including recurrence and perforation. Overall, they are safe and effective.”
Leaks are the second most common preventable cause of death after bariatric surgery with high mortality with delayed diagnosis. The incidence of leaks for bariatric procedures is low ranging from 0.5-2 % for bypass and 0.5-2% for sleeve gastrectomy, compared with 1-6% for other non-bariatric foregut operations.
There are several treatment options for treating leaks and it is ultimately up to the surgeon to decide the appropriate intervention. The first option remains operative management (laparoscopic or open), which includes repair, drainage, and enteral access. Though often required, Kroh claims that this approach may have a significant physiologic impact on already compromised patients. The other end of the management spectrum includes non-operative paradigms, including feeding a person intravenously, intravenous antibiotics, and reliance on a drainage catheter. An emerging and promising third option is endoscopic management, including stent placement. Stent placement has been successfully employed for both gastric bypass and sleeve gastrectomy leaks
“Leaks following laparoscopic sleeve gastrectomy are increasingly common,” he said. These leaks are usually situated at the esophago-gastric junction and can be the result of inappropriate position of the stapler and/or an obstruction or stenosis at the incisura.”
Stent technology has advanced significantly in the past several years. “The stents that are currently available are made of metal or plastic and are fully covered, partially covered, and uncovered,” said Kroh. “Each design has its own advantages and limitations.”
The self-expanding metal stents are designed to exert greater radial force and likely decrease migration rates compared with plastic stents. Partially covered stents facilitate better native tissue in-growth at the exposed ends to anchor the stent when compared with fully covered stents. However this can make stent retrieval more difficult.
Stent placement for leaks after bariatric surgery is typically performed in the operating room under general anaesthetic. A diagnostic upper endoscopy is performed initially to evaluate the local anatomy and identify the pathology. Real-time use of fluoroscopy and contrast injection is helpful. If a stricture is identified, commonly defined as a lumen that does not allow the passage of a diagnostic front-viewing scope, dilation is performed with an appropriately sized balloon.
He also said that additional endoscopic techniques can be employed to improve tissue healing such as injection of tissue adhesives and endoscopic clip deployment to assist leak closure.
Stent size is determined by the endoscopist and it is often dictated by how the bariatric surgery was performed, including specifically stapler size and configuration. When placing a stent, a guidewire is placed and the scope removed. The stent is then advanced and deployed under fluoroscopic direction. Kroh said that endoscopy is repeated to ensure the stent is correctly positioned, and is leak coverage is confirmed by contrast injection with fluoroscopy in the operating room.
Some factors that might reduce the risk of stent migration include appropriate stent selection, anchoring the stent proximally, and regular surveillance after placement. Therefore, patients are followed-up with symptom reports and X-rays. Re-intervention occurs if there are a change in symptoms, clinical parameters, or radiographic stent migration.
Kroh cited his own published study that reported endoscopically placed stents are effective in treating anastomotic complications after upper gastrointestinal surgery and helped to avoid revisional surgery.
The study assessed 18 patients who underwent endoscopic stent placement for anastomotic complications; 14 were bariatric patients. A total of 31 stents (21 covered metal, 5 salivary, and 5 silicone-coated polyester) were used to treat anastomotic leaks (n=13), strictures (n=3), and fistulas (n=2). Symptomatic improvement occurred in all but two patients (89%). Stent treatment was successful in definitively managing the anastomotic complication in 13 (72%) of the 18 patients. Five patients required additional surgical or endoscopic intervention and stent migration occurred in four cases, which were treated by additional endoscopic management.
“The recent advances in endoluminal approaches circumvent the operative field,” concluded Kroh. “And newer technologies, such as absorbable stents and endoscopic suturing systems are being developed with specific applications. These hybrid endo-surgical procedures have been shown to effectively treat complications arising from bariatric surgery whilst still adhering to surgical principles.”