Introduction
Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery
in the world mainly due to favorable weight loss, comorbidity resolution, and a relatively
simple technique [1 ]. Complications after LSG include leaks, bleeding, and strictures [2 ]. Leaks have been reported in the range of 1 % to 2.9 % of cases [3 ]
[4 ] and carry considerable morbidity and mortality. A multidisciplinary approach is
essential to avoid severe long-term morbidity. Endoscopic procedures are commonly
preferred over more invasive surgical approaches and endoscopic septotomy has been
proposed as an effective technique for chronic LSG leak treatment [5 ]. This relatively new procedure allows for fluid drainage from the abscess cavity
into the stomach by dividing the septum that separate the abscess from the gastric
lumen, thus equalizing cavity pressures and promoting secretion flow into the gastrointestinal
tract. These changes result in eventual abscess cavity collapse and clinical resolution.
The aim of this article is to report our experience with this advanced endoscopic
technique with patients that have presented leaks after LSG.
Patients and methods
Institutional Review Board approval was obtained for this retrospective study. Inpatient
admission records from January 2016 to December 2018 were queried to identify all
patients with a diagnosis of post LSG leak and subsequent endoscopic septotomy. Patients
were diagnosed according to symptoms, upper gastrointestinal contrast studies, and
computed tomography (CT scan). Our algorithm for approaching suspected leaks after
LSG is detailed in [Fig. 1 ].
Fig. 1 Leak management algorithm. CT, computed tomography; UGI, upper gastrointestinal series;
NPO: nothing by mouth; HD, hemodynamic; IR, interventional radiology; EGD, esophagogastroduodenoscopy;
TG + EJ, total gastrectomy + esophagojejunostomy; RYGB, roux-en-y gastric bypass;
GJL, lateral gastrojejunostomy.
Technique description
As a precaution, we prefer to perform the operation in a full operating room under
general anesthesia rather than an endoscopy suite. The patient is positioned supine
and a front-viewing endoscope with a disposable distal attachment is used to intubate
the esophagus in the standard fashion. A complete survey of the anatomy must be accomplished
to evaluate the entire stomach in order to rule out distal strictures or axial deviation.
The relationship of the leak orifice to the gastroesophageal junction (GEJ) is determined
and documented. Previous imaging studies should be available to compare with the endoscopic
findings for confirmation of anatomy and location of the leak. We routinely performed
sleeve dilation to address any sleeve axis deviation and treat any possible strictures.
Dilation is performed using a 30 mm achalasia balloon, insufflated to a pressure of
15 psi for 1 minute, and repeated on three occasions. The abscess cavity is then inspected
and entered, if possible, for thorough irrigation. Loose tissue fragments should be
removed and aspirated as needed carefully to minimize contamination while allowing
for removal of necrotic tissue and any foreign bodies. A division of the septum dividing
the gastric lumen and the abscess cavity is carried out using a Triangle Tip Knife
(Olympus, Japan) and electrosurgical energy. Division of the septum is considered
complete when the entire abscess cavity communicates with the gastric lumen, thus
allowing drainage of secretion into the lumen of the stomach. ([Fig. 2 ]) An overview and technical description of the procedure is included for reference.
Fig. 2 Endoscopic images of the abscess cavity separated from the gastric lumen by a a fibrous septum, pre-septotomy procedure and b post-septotomy procedure.
Nutritional support
Nutritional support in patients following an endoscopic septotomy procedure consists
of TPN supplementation and advancing oral feeding as tolerated by the patient. This
approach does not differ in patients with early, late or chronic leaks, as the septotomy
is only performed when there is a well-defined, walled off perigastric abscess cavity,
with no communication with the abdominal cavity.
Results
Five patients meeting inclusion criteria of leak after LSG and treatment with endoscopic
septotomy were identified. All had their primary procedures performed at an outside
hospital. Previous attempts at leak closure (surgical washout, drain placement, stents
or over-the-scope clips placement) were unsuccessful. Three patients had reoperations
and drain placement (one laparotomy and two laparoscopies), and two had percutaneous
abscess drainage prior to transfer. Mean patient age was 51 years (range 40–69), mean
body mass index at the time of septotomy was 40.5 kg/m2 (range 30.8–50.7), and four patients were female. All patients presented due to abdominal
pain. Mean time from LSG to leak presentation was 15 days (range 7–25), and all leaks
were located in the upper third of the sleeve. Mean time from leak presentation to
septotomy procedure was 61 days (range 21–110). Two patients were found to have a
stricture at time of endoscopy; however, all patients were treated with sleeve dilation,
with a particular emphasis on the incisura angularis, before septotomy using achalasia
balloons. Mean operative time was 79 minutes (range 55–125). No procedure-related
morbidity or mortality occurred; however, one patient required repeat septotomy due
to poor clinical improvement. Despite repeated intervention, the patient experienced
treatment failure, ultimately resulting in total gastrectomy with esophagojejunostomy
for definitive management. Mean follow-up for the remaining four patients was 14.25
months (range 6–26), and the average time for success (defined as fistula closure
on endoscopic visualization) was 60.25 days (range 34–82) ([Fig. 3 ]). Postoperative upper gastrointestinal series and computed tomography scans were
used to confirm leak closure. At the time of reported follow-up, patient weight loss
was not affected. All patients continued to lose weight as expected following a LSG.
Patient data are further included in [Table 1 ].
Fig. 3 Endoscopic septotomy result after long-term follow-up (24 months).
Table 1
Cohort of patients who underwent septotomy at our institution.
Gender
Age
Time to leak
Leak location
Stricture
Septotomy
Operative time (min)
Morbidity
Mortality
Additional procedure
Female
43
25
Upper third
No
Yes
71
No
No
0
Female
42
11
Upper third
Yes
Yes
79
No
No
0
Female
40
19
Upper third
Yes
Yes
65
No
No
0
Female[1 ]
69
7
Upper third
No
Yes
55
No
No
Re-septotomy
Male
62
14
Upper third
No
Yes
125
No
No
0
1 Patient who due to septotomy and treatment failure underwent to total gastrectomy.
Discussion
Many factors have been associated with increased risk of leak after LSG [6 ]. Likewise, leaks can be classified according to the time of presentation as acute
(within 7 days), early (within 1–6 weeks), late (after 6 weeks), and chronic (after
12 weeks) [7 ]. Treatment is primarily based on this classification. A systematic review, which
included 4888 patients, described that 79 % of leaks after LSG occurred after hospital
discharge, more than ten days after index surgery [4 ]. In our cohort, all the patients were initially treated at the hospital where the
index operation occurred, with either surgical or percutaneous drainage, stenting,
and broad-spectrum antibiotic therapy. Although no standardized protocol has been
adopted, there is consensus regarding the need to control leakage, establish drainage
of the abscess cavity, and promote closure of the fistula. Non-operative management
for chronic fistulas should be offered whenever possible. Our group only resorts to
surgery for patients in whom all endoscopic options have been exhausted. Moreover,
leak treatment must also include optimal antibiotic therapy, nutritional support,
and adequate drainage.
Endoscopic stents have been proven an effective treatment option for acute or early
leaks with success rates of 84–94 % [8 ]. Most of these devices are covered or partially covered metal and plastic stents
designed for use in the esophagus and colon and repurposed for use in gastric leak
treatment. Migration has been reported up to 60 % and can result in severe morbidity
[9 ]
[10 ]. Mega stents have also been reported as an effective option for leak with the advantage
that they can exclude the entire staple line [11 ]. Specifically designed bariatric stent can also address migration, but these are
not currently available in the United States [12 ]
[13 ]. Stenting of chronic leaks is much less effective with varied success rates ranging
from 19 % to 81% [14 ]
[15 ]. Endoscopic closure of leaks with over-the-scope clip systems can be successful
up to 86 % of the time, but success rates are much lower in cases of chronic leaks
due to difficulty approximating fibrous tissue [16 ]. We believe that the same limitations apply to novel endoscopic suturing devices.
Ultimately, when endoscopic modalities have failed, revisional surgery with conversion
to gastric bypass, gastrojejunal lateral anastomosis, or total gastrectomy with esophagojejunostomy
may be warranted [17 ]. Surgical interventions are not without associated complications and sequelae that
may introduce increased risks over potential benefits [17 ]
[18 ]
[19 ].
Intraluminal pressure of the stomach increases after LSG [20 ] and can lead to a pressure gradient favoring flow through the fistula or leak into
the abscess cavity, thus leading to a vicious cycle further preventing closure. Septum
division allows for equalization of stomach and abscess cavity pressures, which when
combined with aggressive sleeve dilatation, flow can be redirected towards the distal
portion of the sleeve [21 ]. Endoscopic internal drainage has been proven effective in a prior series using
double plastic pigtail catheters to connect the abscess cavity and the lumen of the
stomach [22 ]. Endoscopic septotomy for leaks after LSG was first described by Campos et al. in
2007, borrowing from diverticulotomy principles used in treatment of Zenker’s diverticulae
[23 ]
[24 ]. This technique has been further applied to treatment of leaks after gastric bypass
and biliopancreatic diversion in addition to LSG [25 ].
In this report, we show our experience with endoscopic septotomy for treatment of
patients with late and chronic leaks after LSG, as well as one early leak, with a
success of 80 % (4/5). Septotomy was an option for the patient with an early leak
because of a well-defined abscess wall, even though it was early in the clinical course.
One patient did not respond to endoscopic treatment and needed a total gastrectomy
for definitive management of the leak. In this patient, we believe that endoscopic
septotomy failed because of inability to relieve the distal sleeve stricture, despite
multiple attempts at dilation using an achalasia balloon. Without resolving the distal
stricture, intraluminal sleeve pressures remained high, which did not favor abscess
drainage into the cavity and eventual resolution. Lima [26 ] described his technique in 2014, using endoscopic septotomy for the treatment of
a female patient 30 days after the LSG with complete resolution of the leak at 30-day
follow-up. Moreover, the author discussed use of septotomy in 10 previous patients
with leak resolution no later than 60 days. Baretta et al [25 ] performed septotomies in nine patients after LSG, being successful in 100 % with
just one perforation due to concomitant dilatation. In 2016, Campos et al [27 ] defined their technique using argon plasma coagulation and Needle-Knife (Boston
Scientific, Massachusetts, United States) for septum section in a female patient 60
days after LSG with resolution after two sessions. Mahadev et al [28 ] showed one of the most significant experiences in a multicenter study completed
in the United States. The authors performed nine septotomies, using either Needle-Knife
or argon plasma beam, with 66 % of resolution, and no adverse events related to the
septotomy. Of note, this is the only publication which reports average procedure duration
time of 87.2 minutes, similar to our average time of 79 minutes. Shnell et al [29 ] reported 10 patients with late/chronic leaks after LSG. Septotomy was performed
using argon plasma coagulation plus balloon dilatation in eight patients. The two
remaining patients were treated using through-the-scope dilatation of the fistula
up to 20 mm to achieve septum obliteration with success. Authors did not have any
significant complications or adverse events related to the septotomy procedure. Details
of the three largest series are summarized in [Table 2 ].
Table 2
Largest publications related to septotomy as a treatment for leaks after LSG.
Author (year)
Number of patients
Cutting device
Dilatation
Number of sessions (mean)
Time to septotomy from leak (days)
Time to heal (days)
Baretta (2015)[1 ] [25 ]
9
Needle-Knife or APC
7
1.81
NR
24.67
Mahadev (2017) [28 ]
9
Needle-Knife (3) and APC (6)
5
2.3
60.2
NR
Shnell (2017) [29 ]
10 (6 late and 4 chronic)
APC (8) and BFD (2)
8
5
NR
NR
APC, argon plasma coagulation; NR, not reported; BFD, balloon fistula dilatation.
1 Authors reported their experience with septotomy in gastric bypass and biliopancreatic
diversion as well.
Currently, only argon plasma and Needle-Knife have been reported as cutting devices
to perform septotomy, and due to inflammation, the septum is prone to bleeding. Endoscopists
should use the device and hemostatic technology with which they feel most comfortable.
In our experience, we prefer to use the Triangle Tip Knife instead of argon plasma
and we have not had experienced any bleeding issues [5 ]. Of note, other authors perform selective dilatation of the sleeve only in cases
where a stricture is identified. In our cohort, only two strictures were endoscopically
confirmed, but still dilate all our cases in order to achieve maximum distal gastric
patency for optimal drainage. This aggressive strategy may partly contribute to our
80 % single-session success rate.
The limitations of this study include its small sample size and its retrospective
methodology. Owing to the current low incidence of leak after LSG, developing prospective
randomized-controlled studies could be challenging to design and carry out.
Conclusion
Endoscopic septotomy is a practical and effective approach for patients with early,
late, and chronic leaks after LSG when the perigastric cavity and fistulous tract
are well established. Endoscopic interventions may lead to avoiding high morbidity
surgical procedures. Aggressive endoscopic sleeve dilation allows for improved drainage
of the cavity and a greater chance for success.
