Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections

Abstract

Background and study aims Staple-line leaks occur in 1 % – 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage.

Patients and methods We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies.

Results Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 – 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded.

Conclusions Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods.

^* These authors contributed equally to this work.

• References

• 1 Spaniolas K, Kasten KR, Brinkley J. et al. The changing bariatric surgery landscape in the USA. Obes Surg 2015; 25: 1544-1546
• 2 Galloro G, Ruggiero S, Russo T. et al. Staple-line leak after sleeve gastrectomy in obese patients: a hot topic in bariatric surgery. World J Gastrointest Endosc 2015; 7: 843-846
• 3 Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012; 26: 1509-1515
• 4 Christophorou D, Valats JC, Funakoshi N. et al. Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study. Endoscopy 2015; 47: 988-996
• 5 Baretta G, Campos J, Correia S. et al. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc 2015; 29: 1714-1720
• 6 Roller JE, Provost DA. Revision of failed gastric restrictive operations to Roux-en-Y gastric bypass: impact of multiple prior bariatric operations on outcome. Obes Surg 2006; 16: 865-869
• 7 Csendes A, Braghetto I, León P. et al. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg 2010; 14: 1343-1348
• 8 Southwell T, Lim TH, Ogra R. Endoscopic therapy for treatment of staple line leaks post-laparoscopic sleeve gastrectomy (LSG): experience from a large bariatric surgery centre in New Zealand. Obes Surg 2016; 26: 1155-1162
• 9 Barreca M, Nagliati C, Jain VK. et al. Combined endoscopic-laparoscopic T-tube insertion for the treatment of staple-line leak after sleeve gastrectomy: a simple and effective therapeutic option. Surg Obes Relat Dis 2015; 11: 479-482
• 10 Court I, Wilson A, Benotti P. et al. T-tube gastrostomy as a novel approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case report and review of the literature. Obes Surg 2010; 20: 519-522
• 11 Soufron J. Leak or fistula after sleeve gastrectomy: treatment with pigtail drain by the rendezvous technique. Obes Surg 2015; 25: 1979-1980
• 12 Donatelli G, Dumont JL, Cereatti F. et al. Treatment of leaks following sleeve gastrectomy by endoscopic internal drainage (EID). Obes Surg 2015; 25: 1293-1301
• 13 Campos JM, Ferreira FC, Teixeira AF. et al. Septotomy and balloon dilation to treat chronic leak after sleeve gastrectomy: technical principles. Obes Surg 2016; 26: 1992-1993
• 14 De Lima JH. Endoscopic treatment of post vertical gastrectomy fistula: septotomy associated with air expansion of incisura angularis. Arq Bras Cir Dig 2014; 27 Suppl 1: 80-81
• 15 Haito-Chavez Y, Kumbhari V, Ngamruengphong S. et al. Septotomy: an adjunct endoscopic treatment for post-sleeve gastrectomy fistulas. Gastrointest Endosc 2016; 83: 456-457