Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1116_Библиотеки_им_академика_М_И_Перельмана.pdf
How to Manage Sleeve Complications: Hemorrhage
437
are not biologically active, they rely on patient’s own fibrin production, considered as passive hemostats and are only appropriate for patients who have an intact
coagulation system. Cellulose can be either regenerated to form organized fibers
or non-regenerated with unorganized fibers prior to oxidation. When cellulose fibers are oxidized, conversion of hydroxyl groups to carboxylic acid groups occurs,
yielding to polyuronic acid [61, 62]. The low pH of the carboxylic acid groups
is responsible for several actions: primary local hemostyptic action, secondary
platelet activation to form a temporary platelet plug [61, 62], and proven bactericidal against a broad range of gram-positive and gram-negative organisms [63–
65]. Recently developed oxygenized regenerated cellulose (ORC) hemostat with
structured non-woven fabric, needle punched with interlocking fibers are faster in
hemostasis compared to loose knit structured. The scientific evidence of the use
in bariatric and metabolic surgery is very limited. In gastric bypass surgery Moon
et al. reported excellent experience in stapler buttressing with loose knit structured
ORC versus bovine pericardial strips. With the use of absorbable hemostat as buttress material, the study has shown significant less acute postoperative bleeding at
a lower cost [66]. The use of ORC as a staple line reinforcement is off label, therefore I prefer to use it as a hemostat on the staple line in LSG to prevent bleeding
and rebleeding (Fig. 2). Recently ORC has also been made available as powder.
The structure of the powder penetrates the surface of the blood which saturates the
material, providing a surface for platelet adhesion and aggregation, and initiating
clot formation.
Sealants are low viscosity liquids that polymerize forming a solid film that connects the tissue surfaces [67–71]. This characteristic makes these agents effective
both as sealants and as hemostats. They can be divided in synthetic (cyanoacrylate
and polyethylene glycol-PEG) and semisynthetic (glutaraldhyde albumin-derived)
sealants.
The use of a porous collagen matrix would provide greater hemostatic effectiveness than oxidized cellulose. The protein-binding layer adheres to the collagen pad more rapidly than a fibrinogen–thrombin-coated collagen pad. Hemostatic
Fig. 2 a Oozing staple line b oxygenized regenerated cellulose (structured non-woven fabric,
needle punched with interlocking fibers
K. A. Miller438
pads consist of a sheet-like backing and a self-adhering surface. The various backings include collagen, neutralized oxidized cellulose, or an oxidized cellulose–polyglactin composite; while the active surfaces include fibrinogen and thrombin or a
synthetic, protein-reactive monomer [71, 72].
In bleeding situations where it is difficult to access and visibility is limited,
gelatin matrix sealants might have a great value (Fig. 3). Gelatin-based foam that
flows into the bleeding area serves as a scaffold for platelet adhesion and can be
combined with thrombin to expedite clot formation. The mixture of a flowable gelatin matrix (bovine or porcine) and a human-derived thrombin component are typically prepared immediately before use and directly injected to the site of bleeding
[73–75].
6 Summary
Tissue healing is a dynamic process consisting of continuous, overlapping, and
precisely programmed phases. This includes prompt hemostasis and blood perfusion of the tissue. The right staple height in LSG will find the right balance
between hemostasis without compromising the blood supply and microvascular
invasion. Restricted circulation could be noticed in hand-sewn anastomoses whilst
such lack of vascular supply was not seen in stapled anastomoses. The intramural
arteries passed through the B-shaped staples without hindrance [76, 77].
The versatility and utility of hemostats might replace traditional hemostatic
methods on the staple line (eg, electrocautery, sutures, clips) which might affect
the blood supply and healing process, to improve surgical outcomes with less
bleeding.
Fig. 3 Flowable gelatin
matrix with or without
thrombin in difficult to
access and visibility bleeding
situations
How to Manage Sleeve Complications: Hemorrhage
439
References
1. Shoar S, Saber AA. Long-term and midterm outcomes of laparoscopic sleeve gastrectomy
versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative
studies. Surg Obes Relat Dis. 2017;13(2):170–80.
2. Deitel M, Gagner M, Erickson AL, Crosby RD. Third international summit: current status of
sleeve gastrectomy. Surg Obes Relat Dis. 2011;7:749–59.
3. Chen B, Kiriakopoulos A, Tsakayannis D, Wachtel MS, Linos D, Frezza EE. Reinforcement
oes not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of
the literature and clinical experiences. Obes Surg. 2009;19:166–172.
4. Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging
and primary bariatric procedure. Surg Obes Relat Dis. 2009;5:469–75.
5. Gentileschi P, Camperchioli I, D’Ugo S, et al. Staple-line reinforcement during laparo-
scopic sleeve gastrectomy using three different techniques: a randomized trial. Surg Endosc.
2012;26:2623–9.
6. Zafar SN, Felton J, Miller K, Wise ES, Kligman M. Staple line treatment and bleeding after
laparoscopic sleeve gastrectomy. JSLS. 2018;22(4).
7. Sroka G. Hemorrhagic complications in laparoscopic sleeve gastrectomy. Obes Surg.
2016;26:379–80.
8. Wang H, Lu J, Feng J, Wang Z. Staple line oversewing during laparoscopic sleeve
Gastrectomy. Ann R Coll Surg Engl. 2017;99:509–14.
9. Gagner M, Buchwald JN. Comparison of laparoscopic sleeve gastrectomy leak rates
in four staple-line reinforcement options: a systematic review. Surg Obes Relat Dis.
2014;10(4):713–23.
10. Knapps J, Ghanem M, Clements J, Merchant AM. A systematic review of staple-line rein-
forcement in laparoscopic sleeve gastrectomy. JSLS. 2013;17(3):390–9.
11. Janik MR, Walędziak M, Brągoszewski J, Kwiatkowski A, Paśnik K. Prediction model for
hemorrhagic complications after laparoscopic sleeve gastrectomy: development of SLEEVE
BLEED calculator. Obes Surg. 2017;27(4):968–72.
12. Banescu B, Balescu I, Copaescu C. Postoperative bleeding risk after sleeve gastrectomy. a
two techniques of stapled line reinforcement comparative study in 4996 patients. Chirurgia
(Bucur). 2019;114(6):693–703.
13. Fecso AB, Samuel T, Elnahas A, et al. Clinical indicators of postoperative bleeding in bariat-
ric surgery. Surg Laparosc Endosc Percutan Tech. 2018;28(1):52–5.
14. Babashamsi M, Razavian MH, Nejadmoghaddam MR. Production and purification
of streptokinase by protected affinity chromatography. Avicenna J Med Biotechnol.
2009;1(1):47–51.
15. Aminian A, Brethauer SA, Sharafkhah M, et al. Development of a sleeve gastrectomy risk
calculator. Surg Obes Relat Dis. 2015;11(4):758–64.
16. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric
surgery. N Engl J Med. 2013;369(15):1434–42.
17. Scally CP, Varban OA, Carlin AM, Birkmeyer JD, Dimick JB; Michigan Bariatric Surgery
Collaborative. Video ratings of surgical skill and late outcomes of bariatric surgery. JAMA
Surg. 2016;151(6):e160428.
18. Simper SC, Erzinger JM, Smith SC. Comparison of laparoscopic linear staplers in clinical
practice. Surg Obes Relat Dis. 2007;3(4):446–51.
19. Mery CM, Shafi BM, Binyamin G, et al. Profiling surgical staplers: effect of staple height,
buttress, and overlap on stapleline failure. Surg Obes Relat Dis. 2008;4(3):416–22.
20. Kimura M, Terashita Y. Superior staple formation with powered stapling devices. Surg Obes
Relat Dis. 2016;12(3):668–72.
21. Choi YY, Bae J, Hur KY, Choi D, Kim YJ. Reinforcing the staple line during laparoscopic
sleeve gastrectomy: does it have advantages? A meta analysis. Obes Surg. 2012;8:1206–13.
K. A. Miller440
22. Consten EC, Gagner M, Pomp A, Inabnet WB. Decreased bleeding after laparoscopic sleeve
gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed
absorbable polymer membrane. Obes Surg. 2004;14:1360–6.
23. Shikora SA, Mahoney CB. Clinical benefit of gastric staple line reinforcement (SLR) in gas-
trointestinal surgery: a meta-analysis. Obes Surg. 2015;25:1133–41.
24. Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gas-
trectomy: prospective randomized clinical study comparing three different techniques. Obes
Surg. 2010;20:462–467.
25. Roy S, Yoo A, Yadalam S, Fegelman EJ, Kalsekar I, Johnston SS. Comparison of economic
and clinical outcomes between patients undergoing laparoscopic bariatric surgery with powered versus manual endoscopic surgical staplers. J Med Econ. 2017;20(4):423–33.
26. Fegelman E, Knippenberg S, Schwiers M, et al. Evaluation of a powered stapler system with
gripping surface technology on surgical interventions required during laparoscopic sleeve
gastrectomy. J Laparoendosc Adv Surg Tech A. 2017;27(5):489–94.
27. Bransen J, Gilissen LP, van Rutte PW, Nienhuijs SW. Costs of leaks and bleeding after sleeve
gastrectomies. Obes Surg. 2015;25(10):1767–71.
28. Chiara O, Cimbanassi S, Bellanova G, et al. A systematic review on the use of topical hemo-
stats in trauma and emergency surgery. BMC Surg. 2018;18(1):68.
29. Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M, et al. The science of sta-
pling and leaks. Obes Surg. 2004;14:1290–8.
30. Musella M, Susa A, Manno E, De Luca M, Greco F, Raffaelli M, et al. Complications fol-
lowing the mini/one anastomosis gastric bypass (MGB/OAGB): a multi-institutional survey
on 2678 patients with a mid-term (5 Years) follow-up. Obes Surg. 2017;27:2956–67.
31. Silecchia G, Iossa A. Complications of staple line and anastomoses following laparoscopic
bariatric surgery. Ann Gastroenterol. 2018;31:56–64.
32. Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M, et al. Surgical
strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review
and meta-analysis of 9991 cases. Ann Surg. 2013;257:231–7.
33. Causey MW, Fitzpatrick E, Carter P. Pressure tolerance of newly constructed staple lines in
sleeve gastrectomy and duodenal switch. Am J Surg. 2013;205:571–4.
34. Pinheiro JS, Correa JL, Cohen RV, Novaes JA, Schiavon CA. Staple line reinforcement with
new biomaterial increased burst strength pressure: an animal study. Surg Obes Relat Dis.
2006;2(3):397–9.
35. Kawamura M, Kase K, Sawafuji M, Watanabe M, Horinouchi H, Kobayashi K. Staple-line
reinforcement with a new type of polyglycolic acid felt. Surg Laparosc Endosc Percutan
Tech. 2001;11(1):43–4.
36. Shikora S. The use of staple-line reinforcement during laparoscopic gastric bypass. Obes
Surg. 2004;14(10):1313–20.
37. Stamou K, Menenakos E, Dardamanis D, et al. Prospective comparative study of the effi-
cacy of staple-line reinforcement in laparoscopic sleeve gastrectomy. Surg Endosc.
2011;25(11):3526–3530.
38. Alley J, Fenton S, Harnisch M, Angeletti M, Peterson R. Integrated bioabsorbable tissue
reinforcement in laparoscopic sleeve gastrectomy. Obes Surg. 2011;21(8):1311–5.
39. Nguyen NT, Longoria M, Welbourne S, Sabio A, Wilson SE. Glycolide copolymer
staple-line reinforcement reduces staple site bleeding during laparoscopic gastric bypass: a
prospective randomized trial. Arch Surg. 2005;140(8):773–8.
40. Consten EC, Gagner M, Pomp A, InabnetWB. Decreased bleeding after laparoscopic sleeve
gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed
absorbable polymer membrane. Obes Surg. 2004;14(10):1360–6.
41. Daskalakis M, Berdan Y, Theodoridou S, Weigand G, Weiner R. Impact of surgeon experi-
ence and buttress material on postoperative complications after laparoscopic sleeve gastrectomy. Surg Endosc. 2011;25(1):88–97. English.
How to Manage Sleeve Complications: Hemorrhage
441
42. Sanchez-Santos R, Masdevall C, Baltasar A, Martinez-Blazquez C, Garcia Ruiz de
Gordejuela A, Ponsi E. Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry. Obes Surg. 2009;19(9):1203–10.
43. Ser KH, Lee WJ, Lee YC, Chen JC, Su YH, Chen SC. Experience in laparoscopic sleeve gas-
trectomy for morbidly obese Taiwanese: staple-line reinforcement is important for preventing
leakage. Surg Endosc. 2010;24(9):2253–9.
44. Stamou KM, Menenakos E, Dardamanis D, Arabatzi C, Alevizos L, Albanopoulos K, et al.
Prospective comparative study of the efficacy of staple-line reinforcement in laparoscopic
sleeve gastrectomy. Surg Endosc. 2011;25(11):3526–30.
45. D’Ugo S, Gentileschi P, Benavoli D, Cerci M, Gaspari A, Berta RD, et al. Comparative
use of different techniques for leak and bleeding prevention during laparoscopic sleeve
gastrectomy: a multicenter study. Surg Obes Relat Dis: Off J Am Soc Bariatric Surg.
2014;10(3):450–4.
46. Barreto TW, Kemmeter PR, Paletta MP, Davis AT. A comparison of a single center’s experi-
ence with three staple line reinforcement techniques in 1,502 laparoscopic sleeve gastrectomy patients. Obes Surg. 2015;25:418–22.
47. Albanopoulos K, Tsamis D, Arapaki A et al. Staple line reinforcement with stitch in laparo-
scopic sleeve gastrectomies. Is it useful or harmful? J Laparoendosc Adv Surg Tech A 2015;
25: 561–565.
48. Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International
sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8(1):8–19.
49. El Moussaoui I, Limbga A, Mehdi A. Staple line reinforcement during sleeve gastrectomy
with a new type of reinforced stapler. Minerva Chir. 2018;73(2):127‐32.
50. Sharma N, Chau WY. Remodifying omentopexy technique used with laparoscopic sleeve
gastrectomy: does it change any outcomes? Obes Surg. 2020;30(4):1527–35.
51. Dhillon S. Fibrin sealants (Evicel
®
, [Quixil®/CrossealTM]) a review of its use as supportive
treatment for haemostasis in surgery. Drugs. 2011;71:1893–915.
52. Msezane LP, Katz MH, Gofrit ON, Shalhav AL, Zorn KC: Hemostatic agents and instru-
ments in laparoscopic renal surgery. J Endourol. 2008, 22(3):403–408.
53. Spotnitz WD. Fibrin sealant: the only approved hemostat, sealant, and adhesive-a laboratory
and clinical perspective. Surgery. 2014;1:1–29.
54. Bülbüller N, Aslaner A, Oner OZ, et al. Comparison of four different methods in sta-
ple line reinforcement during laparascopic sleeve gastrectomy. Int J Clin Exp Med.
2013;6(10):985–90.
55. Musella M, Milone M, Maietta P, Bianco P, Pisapia A, Gaudioso D. Laparoscopic sleeve gas-
trectomy: efficacy of fibrin sealant in reducing postoperative bleeding. A randomized controlled trial. Updates Surg. 2014;66(3):197–201.
56. Wagenhauser MU, Mulorz J, Simon F, Spin JM, Schelzig H, Oberhuber A. Oxidized
(non)-regenerated cellulose affects fundamental cellular processes of wound healing. Sci
Rep. 2016;6:32238. https://doi.org/10.1038/srep32238.
57. Lewis KM, Spazierer D, Urban MD, Lin L, Redl H, Goppelt A. Comparison of regenerated
and non-regenerated oxidized cellulose hemostatic agents. Eur Surg. 2013;45:213–20.
58. Ragusa R, Faggian G, Rungatscher A, Cugola D, Macron A, Mazzucco A. Use of gelatin
powder added to rifamycin versus bone wax in sternal wound hemostasis after cardiac surgery. Interact Cardiovasc Thorac Surg. 2007;6:52–5.
59. Sabino L, Andreoni C, Faria EF, Ferreira PSVS, Paz AR, Kalil W, et al. Evaluation of renal
defect healing, hemostasis, and urinary fistula after laparoscopic partial nephrectomy with
oxidized cellulose. J Endourol. 2007;21(5):551–6.
60. Emmez H, Tonge M, Tokgoz N, Durdag N, Gonul I, Ceviker N. Radiological and
Histopathological comparison of microporous polysaccharide hemospheres and oxidized
regenerated cellulose in the rabbit brain: a study of efficacy and safety. Turkish Neurosurg.
2010;20(4):485–91.
K. A. Miller442
61. Pierce AM, Wiebkin OW, Wilson DF: Surgicel: its fate following implantation. J Oral Pathol.
1984;13(6):661–707.
62. Miller JM, Jackson DA, Collier CS. An investigation of the chemical reactions of oxidized
regenerated cellulose. Exp Med Surg. 1961;19(196–201):8.
63. Dineen P. Antibacterial activity of oxidized regenerated cellulose. Surg Gynecol Obstet.
1976;142(4):481–6.
64. Dineen P. The effect of oxidized regenerated cellulose on experimental infected splenoto-
mies. J Surg Res. 1977;23:114–6.
65. Spangler D, Rothenburger S, Nguyen K, Jampani H, Weiss S, Bhende S. In vitro antimicro-
bial activity of oxidized regenerated cellulose against antibiotic-resistant microorganisms.
Surg Infect. 2003;4(3):255–62.
66. Moon R, Teixeira A, Varnadore S, Potenza K, Jawad MA. Reinforcing the staple line with
Surgicel
®
Nu-knit® in Roux-en-Y gastric bypass: comparison with bovine pericardial strips.
Obes Surg. 2013;23(6):788–93.
67. Lewis KM, Kuntze CE, Gulle H. Control of bleeding in surgical procedures: critical
appraisal of HEMOPATCH (sealing hemostat). Med Devices: Evid Res. 2016;9:1–10.
68. Ollinger R, Mihaljevic AL, Schuhmacher C, Bektas H, Vondran F, Kleine M, et al. A multi-
center, randomized clinical trial comparing Veriset
TM
haemostatic patch with fibrin sealant
for the management of bleeding during hepatic surgery. HPB. 2013;15:548–58.
69. Allen MS, Wood DE, Hawkinson RW. Prospective randomized study evaluating a biodegrad-
able polymeric sealant for sealing intraoperative air leaks that occur during pulmonary resection. Ann Thorac Surg. 2004;77:1792–801.
70. Miscusi M, Polli FM, Forcato S, Coman SA, Ricciardi L, Ramieri A, et al. The use of surgi-
cal sealants in the repair of dural tears during non-instrumented spinal surgery. Eur Spine J.
2014;23(8):1761–6.
71. Lewis KM, McKee J, Schiviz A, Bauer A, Wolfsegger M, Goppelt A. Randomized, con-
trolled comparison of advanced hemostatic pads in hepatic surgical models. ISRN Surg.
2014;2014:930803.
72. Fischer CP, Bochicchio G, Shen J, et al. A prospective, randomized controlled trial of the
efficacy and safety of fibrin pad as an adjunct to control soft tissue bleeding during abdominal retroperitoneal, pelvic, and thoracic surgery. J Am Coll Surg. 2013;217(3):385–93.
73. Obermair H, Janda M, Obermair A. Real-world surgical outcomes of a gelatin-hemostatic
matrix in women requiring a hysterectomy: a matched case-control study. Acta Obstet
Gynecol Scand. 2016;95(9):1008–14.
74. Echave M, Oyaguez I, Casado MA. Use of Floseal
®
, a human gelatinthrombin matrix seal-
ant, in surgery: a systematic review. BMC Surg. 2014;14:111–24.
75. Mayol JM, Zapata C. Gelatin-thrombin matrix for intraoperative hemostasis in
abdomino-pelvic surgery: a systematic review. Surg Technol Int. 2013;23:23–8.
76. Hansen H, Sommer HJ, Eichelkraut W. The blood supply of manually sutured and stapled
colonic anastomoses. Langenbecks Arch Chir. 1987;370(2):141–51. https://doi.org/10.1007/
bf01254091.
77. Ballantyne GH, Burke JB, Rogers G, Lampert EG, Boccia J (1985) Accelerated wound heal-
ing with stapled enteric suture lines. Ann Surg. 1985;201:360–4.
Endoscopic Management of Leak and Abscess Following Laparoscopic Sleeve Gastrectomy
Iqbal Siddique
1 Introduction
Laparoscopic sleeve gastrectomy (SG) is currently the most popular primary bariatric surgical procedure for morbid obesity [1, 2]. Approximately 10 to 13% of
patients undergoing this surgery have complications such as bleeding, stenosis,
and leaks [3]. Leaks after SG are typically found at the upper end of the staple
line, near the angle of His, where the staple line meets the gastroesophageal junction because of staple line-height mismatch, ischemia, and unfavorable pressure
gradients secondary to distal intraluminal narrowing of the sleeve [4, 5]. The incidence of leaks or fistulas after SG is approximately 2 to 5% of the cases, and it
is the second most common cause of death after bariatric surgery with an overall
mortality rate of 0.4% [6].
The management of post SG leaks is challenging, resource-intensive and invariably requires a multidisciplinary team approach involving surgery, gastrointestinal
endoscopy, and interventional radiology. The optimum management of leaks and
subsequent intra-abdominal collections following SG is still controversial despite
several reported techniques. The American Society for Metabolic and Bariatric
Surgery position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and non-operative management was published in 2015
[7]. It states that the initial step in the management of an acute leak is to control the infection secondary to the leak. Thus, surgical washout with drain placement is mandatory in a patient whose condition is unstable, with an acute leak
I. Siddique (*)
Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya, Kuwait
e-mail: iqbal.siddique@ku.edu.kw
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_43
443
I. Siddique444
and systemic inflammatory response syndrome or peritonitis, and should not be
delayed. In a more stable patient, any collection should be drained whether surgically, radiologically or endoscopically. In addition to adequate drainage, nutritional support and antibiotics are the mainstays of the treatment.
Leaks after SG may be difficult to seal despite adequate drainage because of
the higher pressures within the sleeve conduit. Because surgical re-intervention is
associated with increased morbidity, non-operative management should be favored
whenever possible [7]. Revision surgery before endoscopic management may also
delay treatment success [8]. Thus, the role of endoscopy in the management of
leaks is usually preferred, and, is being performed more frequently [5].
2 Definitions and Technical Principles of Endoscopic
Management
The role of endoscopy in the scenario of leaks is constantly evolving. Endoscopic
treatment options of leaks vary widely and currently, there is no consensus on
the optimum endoscopic approach to managing SG leaks. In addition, there is
an absence of prospective and randomized trials comparing different endoscopic
techniques. Primary endoscopic closure is rarely successful or feasible for chronic
leak and fistula management. The endoscopic therapeutic strategies have evolved
and have increasingly standardized along two lines of management. The first of
these is closure of the leak site, which generally includes the use of a covered
self-expanding metallic stent (SEMS) to cover the leak [9, 10]. The second strategy is internal drainage, which aims to guide the drainage of the perigastric collection towards the lumen of the gastrointestinal tract and eventually closure of the
fistula tract. When using any of the endoscopic methods to treat a post SG leak, it
is important to manage any downstream stenosis, twist, or kink within the sleeve
that creates an unfavorable pressure gradient to enhance drainage and resolution.
Optimizing the pressure gradient allows closure of the cavity by secondary intention, through granulation tissue formation and fibrosis [11].
2.1 Definition of Post SG Leak
The clinical presentation of post SG leak is defined according to the modified UK
Surgical Infection Study Group classification [12]. The presence of a leak is confirmed by upper gastrointestinal swallow study or abdominal computed tomography. Leaks are classified as acute (≤1 week), early (1–6 weeks), late (6–12 weeks),
and chronic (>12 weeks) according to the Rosenthal classification [1].
2.2 Definition of Post SG Leak Healing
Healing of post SG leak is usually defined as resumption of oral feeding and
the absence of (1) percutaneous drainage; (2) leakage of contrast agent seen on
Endoscopic Management of Leak …
upper gastrointestinal swallow study or abdominal computed tomography; (3)
intra-abdominal collections; and (4) flow through a previous surgical path (such as
gastro-cutaneous fistula).
445
3 Closure of the Leak Site
The first principle of management of post SG leaks is closure of the leak site,
which generally includes the use of a covered SEMS to cover the leak [9, 10] but
may also include the use of through-the scope or over-the-scope and clips (OTSC)
[13], and endoscopic suturing [14]. Endoscopic treatment of post SG leak with
the placement of a covered SEMS or clips should only be done after abdominal
collections have been drained either surgically or percutaneously before stent
placement. In cases involving inaccessible, especially large, collections, the stenting should be postponed or abandoned.
3.1 Self-Expanding Metal Stents
SEMS have been the most widely studied devices for endoscopic management
of SG leaks. SEMS have been used for the palliation of dysphagia in esophageal
cancer since the early 1990s [15]. Although primarily used to palliate malignant
strictures, other indications for SEMS placement now include strictures from
extrinsic compression, malignant perforations and fistulas, and, more recently,
benign conditions such as recalcitrant esophageal strictures, perforations, fistulas,
post-surgical leaks and bleeding esophageal varices [16].
SEMSs are relatively easy to place and are widely available in most endoscopy units. One benefit to their use, compared to other endoscopic modalities for
SG leaks, such as OTSC, suture, and internal drainage, is that SEMS placement
does not require endoscopic navigation and identification of the leak or fistula orifice, which can be often difficult to locate. The SEMS coating isolates the leak
orifice from gastric contents and allows re-feeding during the healing process
(Fig. 1). There is evidence that high intragastric pressure from either mechanical or functional stenosis in the SG may contribute to persistent leak and delayed
healing, which can be also be successfully managed by SEMS placement [17, 18].
However, covered SEMS placement for the treatment of post SG leaks should be
performed in patients with adequate external drainage of the perigastric collection.
It should be mentioned that the use of SEMS for the management of leaks after
SG is currently not Food and Drug Administration approved, and is an off-label
use of the device.
3.2 Types of SEMS
Commercially available stents are usually made of a shape-retaining nickel
and titanium alloy (nitinol) and covered with polyurethane or silicone. Partially
Fig. 1 Acute unorganized
leak with peritoneal spread
treated by covering the leak
site with a fully covered
self-expanding metallic stent.
Reprinted from Vargas EJ,
Abu Dayyeh BK. Keep calm
under pressure: a paradigm
shift in managing postsurgical
leaks. Gastrointest Endosc.
2018;87:438–441 [11], with
permission from Elsevier
I. Siddique446
covered SEMSs have a portion of the exposed bare metal at the proximal and
distal ends, which allows for ingrowth of surrounding tissue and could increase
watertightness. Fully covered SEMSs do not have any exposed bare metal at either
end. Partially covered stents have less risk of migration because of hyperplasia
and ingrowth of tissue into the uncovered ends [19]. However, tissue ingrowth
into the uncovered end also makes their removal more difficult resulting in tissue
trauma and limits placement for a longer period. Fully covered stents, on the other
hand, are more prone to migration but are easier to remove. New, extra-long, fully
covered SEMSs have been developed especially for post SG leaks, such as the
MEGA esophageal stent (Taewoong Medical, Gyeonggi-do, South Korea) and the
Hanarostent (MITECH, Seoul, South Korea). These SEMS are available in lengths
up to 23 cm and 24 cm, respectively, and are associated with less incidence of
stent-specific complications such as migration and difficulty with removal [20,
21]. These stents are currently not available in the United States.
3.3 SEMS Insertion Procedure
All endoscopic procedures for placement of SEMSs for post SG leaks should
be performed under fluoroscopic guidance with patients under general anesthesia. Once the site of the leak is identified, it should be marked with an external
radio-opaque marker taped to the patient’s skin (Fig. 2). A stiff guidewire is then