Low-cost modified endoscopic vacuum therapy using a triple-lumen tube allows nutrition and drainage for treatment of an early post–bariatric surgery leak

Leaks after laparoscopic sleeve gastrectomy (LSG) occur in up to 5 % of patients, with mortality rates approaching 4 % [1]. Among available therapies for leaks after bariatric surgery, endoscopic approaches have been shown to be safe and effective. Tissue sealants, cap-mounted clips, suturing, stents, a cardiac septal defect occluder, septotomy, endoscopic internal drainage with double pigtails, and endoscopic vacuum therapy (EVT) are the forefront of the therapeutic endoscopic arsenal [2] [3]. However, an individualized approach is needed to determine the best endoscopic treatment strategy for a given patient. In this video, we describe the successful treatment of a LSG leak using low-cost modified EVT.

A 30-year-old woman with class II obesity developed fever, nausea, and abdominal pain 14 days after LSG. Computed tomographic scan revealed a leak associated with a small contained collection adjacent to the staple line of the proximal stomach (angle of His). Underwater esophagogastroduodenoscopy was performed without air insufflation to avoid disrupting the collection ([Fig. 1]). The patient was treated with modified EVT using widely available triple-lumen tubing to allow for nutrition using the jejunal tube and EVT using the fenestrated portion of the tube ([Video 1]). The procedure was well tolerated and the patient remained on enteral nutrition as well as taking a liquid diet on the day following the procedure. External drainage was not required. After 15 days, imaging demonstrated resolution of the leak ([Fig. 2]), and the modified EVT system was removed ([Fig. 3]).

Fig. 1 Underwater endoscopic visualization of the sleeve leak.

Video 1 Low-cost modified endoscopic vacuum therapy with a triple-lumen tube.

Fig. 2 Fluoroscopic imaging confirmed the success of leak treatment with the low-cost modified endoscopic vacuum therapy (EVT) system and demonstrated a significant improvement in the sleeve stenosis.

Fig. 3 Complete healing of the leak after one session of the modified EVT treatment.

In summary, endoscopic drainage with this low-cost, modified EVT is a highly effective and safe technique for leaks [4] [5]. Furthermore, EVT obviates the need for external drainage and employs widely available materials. Ultimately, this low-cost modified EVT allows for nutrition and drainage with a single tube through the nares, enabling decreased procedure times, longer periods between EVT system exchanges, and fewer adverse events.

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• References

• 1 Hamid HKS, Emile SH, Saber AA. et al. Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis. Surg Endosc 2021; 35: 1025-1038
• 2 de Moura DTH, Sachdev AH, Thompson CC. Endoscopic full-thickness defects and closure techniques. Curr Treat Options Gastroenterol 2018; 16: 386-405
• 3 do Monte Jr ES, de Moura DTH, Ribeiro IB. et al. Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: systematic review and meta-analysis. Dig Endosc 2020;
• 4 Loske G, Schorsch T, Rucktaeschel F. et al. Open-pore film drainage (OFD): a new multipurpose tool for endoscopic negative pressure therapy (ENPT). Endosc Int Open 2018; 6: E865-E871
• 5 de Moura DTH, de Moura BFBH, Manfredi MA. et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11: 329-344