Sleeve gastrectomy (SG) is a restrictive gastric procedure used to treat obesity. It is the most frequent bariatric surgery in the United States,1 and the second most common bariatric surgery worldwide, preceded only by Roux-en-Y gastric bypass (RYGB).2 Its prevalence has been steadily rising due to the decline in all other bariatric surgical procedures including: RYGB, laparoscopic adjustable gastric banding (LAGB) and biliopancreatic diversion/duodenal switch (BPD/DS).3 SG represents 59% of all bariatric procedures performed in 2017 in the United States.1,4
The procedure comprises vertical longitudinal resection of the gastric greater curve including the fundus, body, and antrum (Figs. 1, 2), and formation of a tubular shaped conduit with a capacity of <100 mL.5 On average, 80% of the stomach is excised, and the pylorus is usually preserved to preserve normal physiological gastric emptying.5 Historically this procedure was created as an adjunct procedure to BPD, and as a bridging procedure for weight loss before RYGB or BPD.6 However, SG is now performed as a single procedure for weight loss, without additional surgery due to the significant effect on weight loss produced by SG alone.7
Its popularity is attributed to its technical ease, and absence of enteric anastomosis, intestinal bypass, or external hardware.8 Lack of dumping syndrome and low incidence of marginal ulcerations are further advantages.9
Weight loss is achieved by restrictive and humoral effects of the gastric sleeve. The restrictive capacity of the gastric remnant8 decreases stomach distensibility and increases intraluminal pressure leading to reduction in bolus volume that can be accommodated.5 In addition, resection of the gastric fundus diminishes the humoral effect of ghrelin-producing cells, decreasing postprandial levels of ghrelin and promoting satiety.10 An incremental increase of glucagon-like peptide 1 (GLP-1) and peptide-YY further promotes weight loss.11
SG is positioned between RYGB and LAGB when both net weight loss and complications are considered. It produces higher net weight loss than LAGB but is associated with higher complication rates than LAGB, and produces lower net weight loss than RYGB but is associated with lower complication rates than RYGB.3,12–15 Nevertheless it provides similar short-term and medium-term weight loss to RYGB.2,16 Estimated weight loss at 1, 3, 5, and 8 years after laparoscopic sleeve gastrectomy (LSG) is 86%, 63%, 61%, and 52%, respectively,17 and at 5-year follow-up the average body mass index (BMI) is 30.2 (SD=5.5, range=0 to 60).18,19 There is also improvement or resolution of other obesity-related diseases including diabetes mellitus,20 hypertension,21 hypertriglyceridemia,22 obstructive sleep apnea,23 and nonalcoholic steatohepatitis (NASH) scores.24 On the other hand, increased intragastric pressure results in regurgitation, and reduced gastric emptying with decreased lower esophageal sphincter pressure2 lead to worsening or new onset of gastroesophageal reflux disease.17,18
COMPLICATIONS OF SG
Overall morbidity ranges from 0% to 17.5%, and overall mortality is 0% to 1.2%.14,17,25–28 At 30 days follow-up, the complications, readmission and reintervention rates position SG between LAGB and RYGB, with 5.6%, 5.4%, and 2.97%, respectively, whereas there is no significant difference in mortality.3 Similar complication rates are noted in the elderly and adolescents29–32 making SG a feasible option in these subpopulations.
Early postoperative complications include vomiting (23%), dehydration (19%), ileus (18%), bleeding (3%), and anastomotic leak (0.1%).17 According to the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Data Registry (MBSAQIP), most common complications at 30 days are anastomotic leak, bleeding requiring transfusions, urinary tract infection, and organ space infection (0.76%, 0.57%, 0.31%, 0.29%, respectively).14 Similar findings are reported in the Bariatric Outcomes Longitudinal Database 2008-2012, with most common 30-day complications being bleeding (0.5%) followed by leak (0.2%), and pulmonary embolus (0.1%).14 Gastrointestinal bleeding and leaks are complications with the largest overall impact on end-organ dysfunction, reoperation, and intensive care unit admission.33,34 Late complications include late strictures, gastroesophageal reflux disease, and incisional hernias.17,23 Leaks are the second most common cause of mortality in patients with SG, after pulmonary embolism.35,36
Leak is defined as outflow of luminal contents from a surgical anastomosis between 2 hollow viscera.37 The term leak is often interchangeably used with fistula, but there are certain differences. Leak represents a disruption of surgical anastomosis resulting in a communication between intraluminal and extraluminal (epithelialized or nonepithelialized) compartments, while fistula is an abnormal (surgical or nonsurgical) communication between 2 epithelialized surfaces.38–42 A fistula communicates externally with the skin, or internally with peritoneal, retroperitoneal or thoracic space.43 The fistula itself can epithelialize, which adversely affects spontaneous closure and treatment success.41,43,44 Chronic and untreated leak can transform and organize into fistula.41,45 Complex fistula forms when multiple fistulae are connected, arising from different organs.42 Luminal contents from both sources can cause fevers, sepsis, abscesses, and metabolic derangements. In the absence of clinical symptoms, the escape of luminal contests from the anastomotic site into an adjacent localized area detected by imaging, is defined as a subclinical leak or fistula.37
Leak development rate after SG ranges 1.85%±2.47% (median, 1.1; range 0% to 10%) based on a recent systematic review,46 and most prior studies report leak rate of <7%.3,8,9,47–53 The overall trend has been decreasing due to better recognition and prevention of potential risk factors.48,54 Most leaks occur at the proximal (cranial) location of the staple anastomosis, with 90% of cases at the gastroesophageal junction (GEJ) and angle of His (acute angle between the abdominal esophagus and gastric fundus).9,47,55–60
SG leak has a significant economic burden because it takes a long time for complete resolution (median time: 310 d; range: 9 to 546 d), and is accompanied by multiple tests, procedures, and hospitalizations.61,62 In one study from the Netherlands, median additional cost for leak was €9284 (range €1748 to 125,684), with the majority coming from hospitalization at 50%, and from ICU care at 30%.62 Another study revealed higher mean cost of €22,470.63 Interestingly, leaks are the most frequent reason for medico-legal litigation in the bariatric population, and were the legal indication in 68% of gastric sleeve patients filing a claim.64
Pathophysiology and Risk Factors
Although LSG does not involve an anastomosis, it is more susceptible to a leak than RYGB (2.4% vs. 0.7%) due to the long staple line and high intraluminal pressure.9,47,65 Multiple surgical and nonsurgical risk factors are involved in the pathophysiology and development of leak (Table 1).
TABLE 1 -
Risk Factors, Pathogenesis, and Prevention of Sleeve Gastrectomy Leaks
|Leak Risk Factors
||Mechanism for Development of Leaks
|Surgical risk factors
| Stapling technique66,67
||Pathologic tissue creep and shear stress
||Allow adequate time for tissue compression and creeping while preventing excessive tensile stress (wait 15 s before repeat firing)
| Undersized staples54,66–92
||Inadequate staple formation or excessive tissue compression, exceeding tissue’s tensile strength, leading to tearing and perforation
||Use appropriate size staple cartridges (different colors) in different portions of the stomach
| Full thickness oversewing past a fixed staple line66
||Increased risk of tearing at the point of suture penetration; latter development of strictures
||Consider staple-line buttressing instead (mixed results); consider use of absorbable polymer membrane or sealant; avoid oversewing and avoid use of both buttressing and oversewing
| Migratory crotch staple causing staple misfire66,67,69
||Weak staple line
||Detect and remove the crotch staple, perform methylene blue test
| Inadvertent stapling near the angle of HIS or gastroesophageal junction47,66,67,76,93
||Avoid stapling close to the esophagus in the cardia area, stay 1.5 cm away from the incisura and 1 cm away from the angle of His; perform methylene blue test
| Aggressive dissection with heat instruments35,71,76,94,95
||Localized ischemia by ligation of short gastric arteries
||Stay 1.5 cm away from the incisura and 1 cm away from the angle of His; avoid disrupting blood supply to the proximal stomach in the cardia region
| Bougies <40 Fr in size77,96–98
||Stricture development and increased intraluminal pressure
||Use bougies >40 Fr
| Stenosis, strictures, mechanical/physiological obstruction, sleeve angulation, spiral sleeve shape67,69,99–102
||Increase in intraluminal pressure
||Begin the gastric transection 5-6 cm from the pylorus; maintain proper traction on the stomach before firing; use left-hand stapling; keep staple line straight while symmetrically resecting anterior and posterior walls of the stomach; keep distance >1.5 cm from the incisura
| Surgical experience, training level and number of sleeve gastrectomy performed69,81,92,103–108
||Learning curve, iatrogenic factor
||Minimum 100 procedures under supervision; ideally supervision of initial 1000 sleeve gastrectomies; goal of >43 cases per surgeon per year; consider performing methylene blue test
| Procedural time; every additional 10 min associated with increased odds of 1-year leak109,110
||Operative time as a marker for quality of care in bariatric surgery
||Increase and avance surgical skills, prolong training
| Surgical approach (primary or conversion)54,111,112
||Attempt for laparoscopic approach; if conversion if expected, then start with primary laparotomy instead of laparoscopy (history of prior abdominal surgeries); avoid robotic sleeve gastrectomy
|Nonsurgical risk factors
| Super obesity (BMI>50)9,54,113
||Altered/inadequate response to incision healing and scar formation; poor blood supply; microangiopathy
||Weight loss before surgery
||Appropriate management of hyperglycemia
| Sleep apnea48,54,116
||Sleep apnea treatment
| Chronic use of steroids117,118
||Taper down steroids, use lowest dose possible
||Preoperative dietitian/nutritionist management
| Sarcopenic obesity119
||Treatment of GERD
| Male gender54,56,121,122
BMI indicates body mass index; GERD, gastroesophageal reflux disease.
Surgical Risk Factors
Sleeve stapling and suturing are a major factor in developing and preventing leaks. The different thickness of various parts of the stomach wall (with the fundus being the thinnest at 1.7 mm)123 makes use of different staple sizes important. Under-sizing staple cartridge may lead to excessive tissue compression that exceeds its tensile strength, resulting in tears and perforation.66 Full-thickness over sewing past a fixed staple-line may increase the risk of tears at the point of suture penetration in the distended gastric pouch.66 Migratory crotch staple can cause staple misfire that may not be evident immediately but predisposes to future leaks.66 Firing a staple near the angle of HIS may cause staple migration which can weaken the staple-line.
Ischemia and necrosis may contribute to leak formation, which can lead to late leaks.124,125 This frequently occurs at the angle of HIS, where take-down of the short gastric arteries leads to relative ischemia.9,55 Devascularization of this tissue with aggressive dissection using heat instruments is one mechanism that can lead to ischemic necrosis and leak formation.35
Gastric stenosis is also a major contributor to leaks. In an already noncompliant tubular stomach with an intact pylorus, stenosis, can appreciably elevate the intraluminal pressure that will exceed the strength of the tissue and the staple-line, resulting in a leak.5,65,126–128 A kink or stenosis at the incisura may predispose to an upper staple line leakage, by increasing and distending the lower esophagus and stretching the staple line just below.96,124,125 Use of smaller bougies or stapling too close to the bougie can also cause stricture by increasing retrograde pressure. In addition, twisting the staple line, causing a spiral sleeve, can ultimately result in mechanical stenosis.68
Experience of the surgeon and number of procedures performed are inversely associated with leaks.69,103,104 Leak rate <1% can be achieved in surgeons performing >43 cases per annum.104
Nonsurgical Risk Factors
Obesity is a potential risk factor for leaks, mostly in the super-obese population (BMI>50 kg/m2).9,54,113 Diabetes is also linked to higher rates of leak after gastrointestinal surgeries in some studies,114–116 but other studies failed to show an association.129 Sleep apnea and male gender were associated with higher leak rates in one study.54 Hypertension and age above 55 years at the time of surgery have been suggested as potential risk factors for development of leaks based on data in Roux-en-Y patients.35,48,113,116,121,130 Chronic corticosteroid use was associated with a higher leak rate in one study (0.6% vs. 0.3%, relative risk=2.2, P=0.03).117,118 Oxygen dependency represented an independent risk factor for leak on multivariate analysis when both RYGB and SG patients were included,48 but this was not shown when only SG patients were analyzed.131Helicobacter pylori infection does not influence postoperative outcomes in SG patients and is not associated with increased incidence of leak.132–136
Eliminating these risk factors are necessary to prevent development of a leak and its complications (Table 1). Avoiding stapling too close to the cardia and GEJ may be effective to reduce the incidence of leaks.93 Spending adequate time for compression of gastric tissue with stapling device is also necessary to prevent a leak93,126 as well as use of different sizes of staples. Surgical factors that may decrease leak incidence include intraoperative use of fibrin sealant and staple line buttressing, but the available data are limited.66,70,93,96,97,137,138 Reinforcement of staple line with absorbable polymer membrane decreased leaks in one study.52 Oversewing did not demonstrate significant benefit.139,140
Use of ≥40-Fr bougie was associated with lower leak incidence compared with the use of bougie size <40-Fr,9,67,93,96,97,141 with the log of the bougie diameter inversely proportional to the percentage of leaks.125 Some experts believe that greater experience and high-volume centers can achieve similar success with smaller size bougies as well.142
Immediate treatment and management of functional stenosis (tissue edema, hematoma) may prevent leak formation by decreasing the pressure in the acute period. This can be achieved by nasogastric tube decompression, adequate intravenous hydration, use of intravenous antiemetics, and enteral or parenteral feeding.143,144
Intraoperative Detection of Leak
Intraoperative leak tests can identify otherwise undetectable areas of staple line disruption that prompts immediate treatment and closure to prevent further development and complications of leak.47,71,125,145–147 Nevertheless, their routine use is still debated.48,56,148–152 Most common intraoperative leak tests include: intraoperative endoscopy, air leak testing, and transgastric dye injection. Use of 100 to 150 cm3 of air to insufflate the stomach through a nasogastric tube or endoscope can be used to detect air bubbles indicating leakage.47,145,153 Methylene blue infused at the end of surgery71,148,154–156 administered via a bougie as a solution of 80 to 120 mL while the duodenum is transiently blocked with forceps, allows for accumulation in the stomach, distension of the stomach and ultimately, can reveal leakage.156
Intraoperative detection of leak decreased the incidence of postoperative leak by allowing intraoperative repair in most cases.156 Contrariwise, leak test may inadvertently damage the anastomoses and staple line. Two retrospective studies evaluating the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database revealed that the intraoperative leak test was associated with increased rates of postoperative leak.48,53 Intraoperative leak test currently remains controversial, and there is no data indicating which type of leak test is superior among methylene blue, nasogastric tube, or endoscopic air leak test.
Clinical presentation varies widely including: asymptomatic patients diagnosed by routine imaging,156 symptomatic patients, and ultimately, patients with septic shock.157 Presentation depends on location of the leak and its onset following surgery.158 In most cases leak was not evident postoperatively, and occurred after discharge, with 50% of cases reporting leak >10 days after surgery (11 to 31 d).9 Presentation is delayed in the absence of a surgical drain postoperatively.41
Symptomatic patients present with abdominal pain (predominantly epigastric), and less commonly chest or left shoulder pain.143,158 Objective signs suggesting leak include: tachycardia, fever, tachypnea, and hypotension consistent with systemic inflammatory response syndrome. Tachycardia is a principal presenting feature in most patients,50,143,158–160 but can be nonspecific. Therefore, fever is the most important clinical factor to suggest leak143,161 and unexplained fever and tachycardia postoperatively should raise the index of suspicion for further diagnostic testing.50,125,162,163 Chronic leaks have a more insidious onset of symptoms compared with acute leaks.164
Frequently encountered laboratory abnormalities include elevated leukocyte count and c-reactive protein (CRP).143,158,165 CRP levels are elevated postoperatively and appear to peak around postoperative day (POD) 3.166 CRP levels at POD 1 <6.1 mg/dL predicts risk of leaks <2% in asymptomatic individuals.167,168 Contrariwise, persistently elevated CRP levels after POD 3 are concerning for presence of postoperative infectious complications including leaks.166
Most common tests used to diagnose leak include upper gastrointestinal (UGI) fluoroscopy and computed tomography (CT) scan of the abdomen with oral contrast.169 Laparoscopy is the golden standard test used to diagnose leak, but is rarely used solely for diagnosis due to its invasiveness.47,169 In a large meta-analysis, UGI series had sensitivity of 56% and specificity of 99% in diagnosing leak.170 In a head to head comparison, CT with oral contrast is superior to UGI series with a sensitivity of 95% versus 79.4%, respectively.169 Therefore, CT is considered as the best noninvasive test for detection and confirmation of leak9,56,125,143,162,165,171–173 and should be triggered by clinical suspicion.173,174 However, UGI series remains important in evaluating the location and size of leaks even after a leak is identified by cross-sectional imaging.164
There is a lack of consensus regarding postoperative use of imaging for screening and early detection of leaks.47,175,176 However, routine UGI evaluation after bariatric surgery remains a common practice in some accredited centers and is associated with prolonged hospital length of stay, without significant improvement in leak rate diagnosis.177 A selective strategy of postoperative UGI series use was found to be noninferior to a liberal strategy in terms of postoperative outcomes.176 Some authors recommend a selective postoperative use of CT scan because of its superior sensitivity.173,175
CLASSIFICATION OF LEAKS
Various authors classify leaks differently with most classifications entailing 3 major components: presence of fluid collection, onset after surgery, and location50,178–186 (Fig. 3, Table 2). On the basis of these components, further approach to leak management is designed, using adequate endoscopic, radiologic, and surgical steps.10,143
TABLE 2 -
Classification of Sleeve Gastrectomy Leaks
|Based on fluid collection characteristics50,178,181,182,184,185
| Type I leak50,178,181,182,184,185 (small, incidental, subclinical, asymptomatic, radiologic)
||Fluid collection absent. Presence of fistulous track without generalized spillage or dissemination to the adjacent cavities
||Does not require drainage
| Type II leak143,185,187 (large, major, clinical)
||Fluid collection present. More generalized dissemination into the abdominal or thoracic cavity can occur
||Usually symptomatic requires drainage
||Contained (organized): no internal or external drainage apart from collection
||Consider endoscopic therapy
||Uncontained (disorganized) aka Type III: presence of internal / external drainage outside the fluid collection
||Low threshold to consider surgical revision/management
|Onset after sleeve gastrectomy40,41,68,188
||Within 7 d
||Wall defect closure or diversion strategy more successful in this group;
||Within 1-6 wk
||After 6 wk
||Drainage strategy; may require ablation or abrasion of epithelial lining of fistulous tract
||After 12 wk
||Near the angle of His
||Difficult positioning in proximal leaks may interfere with adequate closure; may consider SEMS if unable to navigate directly to fistula orifice
||Mid or lower portion of the remnant gastric tube
Presence of fluid collection and determining its containment is the most important step in classifying leaks and has a major impact on its management.185 Radiologic leak represents leak detected on imaging, without presence of localized collection and without clinical signs. It is also known as type I leak, small leak, subclinical leak, or incidental leak. The other form is called type II leak, also known as large leak or major leak, and is defined as presence of leak and fluid collection that is usually symptomatic.178 Some authors also report type III leak that recognizes a connection to the peritoneal space/skin and signifies lack of containment of the leak.185 At this point, there is no universally accepted nomenclature and various authors use different designations.178 Therefore, when defining a leak, rather than searching for an adequate designation, it is best to describe the presence of fluid collection and its containment.
On the basis of timing of onset after SG, 4 types of leaks are recognized: acute (presentation <7 d), early (presentation at 1 to 6 wk), late (presentation at 6 to 12 wk), and chronic (presentation after 12 wk of initial surgery).47,68 Classifying leaks chronologically is very important because different treatments are more effective in certain periods.189
On the basis of location, leaks are classified into 2 separate groups: proximal (near the angle of His) and distal (distally to the angle of His).68,143
OVERVIEW OF MANAGEMENT
Managing leaks has varied amongst experts and is based on personal experience. Therefore, at present there is a lack of consensus in approaching and treating leaks.35,41,55,56,94,102,125,181,185,189–201 Lack of prospective, randomized controlled trials renders guidelines more difficult, and most data come from retrospective studies, reviews, and expert opinions.125,137,187,191
A multidisciplinary approach including surgery, gastroenterology, and interventional radiology is essential to manage these complex patients.45 Prompt diagnosis, classification and treatment of leaks is essential.143,154 Delayed management on the other hand (diagnostic testing, antibiotics, and reintervention) leads to worse outcomes and is the most common reason for culpable fault in medico-legal claims of patients undergoing bariatric surgery.64
Treatment strategy depends on patient’s clinical condition and leak classification. It includes 3 mainstays: medical support, drainage of leaked material, and repair of the wall defect.35,56,144,194,199,202 Medical support entails early use of intravenous antibiotics, intravenous hydration, and nutrition.143,144,203 Antibiotics should empirically cover Klebsiella, Streptococcus, and Pseudomonas until definitive culture results are obtained.204 Addressing nutrition is a key step to enable the patient to heal the fistulous communication, and early nutrition (enteral/parenteral) is very important step in the healing process.205
Assessing patient’s clinical stability will guide further management. In the presence of hemodynamic instability, septic shock, or diffuse peritonitis, further surgical management is essential.50,171,181,206,207 For the rest, endoscopic treatment is preferred, due to high perioperative morbidity with surgery143,208 (Fig. 4).
Surgical management of leaks is associated with significant morbidity and mortality; therefore, its use is restricted to patients with sufficient indications (hemodynamic instability, septic shock, diffuse peritonitis), and alternatives are considered for the rest.162,209,210 Nevertheless, surgical revision may have a lower morbidity than once believed, as more recent studies show better outcomes with morbidity of 5% and no mortality.211 Prompt surgical intervention requires washout, drainage, and debridement of the leak, followed by leak closure.71,125,137,212 Surgical intervention is accompanied by nothing by mouth, administration of antibiotics, and enteral or parenteral nutrition.143,144,203 Surgery may be followed by esophageal stent placement, excluding the area from further pressure and injury.66,143,181 Use of rendezvous technique has also been described where endoscopy aids in identifying the leak intraoperatively by use of a guidewire.125 Closure of the defect is less successful after POD 3 due to poor healing, presence of significant inflammation, and necrosis.9,143,213 Certain authors warn against direct surgical closure due to presence of friable and inflamed tissue with ischemic edges, making reoperation unsuccessful.171,214 Laparoscopic approach has higher success rate than laparotomy (81% vs. 43%, respectively).215
Surgical management also has a role as a step up, escalation therapy, when more conservative treatments fail.199,216 In hemodynamically stable patients a trial of nonsurgical interventions should be attempted for at least 3 months before considering surgery.47,68,188,195,217,218 Surgical approach is preferred after 6 months of failure with conservative methods, because the probability of healing following endoscopic treatment is significantly decreased (from 76.4% at 1 mo to 48.5% at 6 mo).197 Presence of loculated subphrenic collection or abscess is an independent variable associated with the need for surgical revision.188
Alternative surgical methods to primary closure include: fistula excision, fistulojejunostomy, conversion to RYGB, and jejunal patch.215,216,219–226
If there are no signs of hemodynamic compromise, septic shock or peritonitis, endoscopic management should be attempted, to offer a less invasive alternative to surgery.10,47,187,227,228 Successful endoscopic therapy depends on leak onset with success of 74% to 85% in early leaks.55,197,229–231 Leaks that persist have much lower rates of endoscopic healing.197,231 In one multicenter retrospective study, endoscopic therapy achieved healing in 81 patients overall (73.6%), but the probability of successful endoscopic therapy decreased markedly with time, from 76.4% at 1 month, to 48.5% at 6 months.197 This highlights the importance of early diagnosis, since up to 80% of leaks are diagnosed after hospital discharge and >10 days after surgery.9 Predictors of successful healing following endoscopic treatment include: acute leaks developed ≤3 days after gastric sleeve, early endoscopic treatment <21 days after leak diagnosis, leak size <1 cm and absence of history of gastric banding.197
When determining the appropriate endoscopic approach for closure of luminal defects, certain fundamental principles are considered. As a short summary, the endoscopic strategy relies on the application of a sequential therapeutic program of the successive mapping of the leak (endoscopic and/or fluoroscopic), debridement and drainage or diversion (if indicated), and closure of persistent leaks192,205,232 (Fig. 5). Drainage of undrained cavities and collections should precede closure.137,203,233
Presence of intra-abdominal collections determines the need for drainage.216 Undrained collections should be drained externally (percutaneously) by surgical or radiologic approach, or internally by endoscopic approach.47,192,205,234–236 Rapid and adequate drainage is of paramount importance in treatment of SG leaks,45,137 because this eliminates the focus of sepsis.41 If a fistula with established epithelialized tract is present, ablation of the epithelial lining using cytology brush, endoscopic resection or thermal therapy (APC) is necessary before closure is attempted.40,42,45
The size, viability of surrounding tissue and location of the defect should be defined based on which further endoscopic closure strategy is developed.41,205,234 Finally, treatment of distal stenosis if present, and removal of foreign material (drains, staples, sutures) is important for successful treatment of SG leaks.10,233 Endoscopic management should always be performed under CO2 insufflation, which reduces risk of pneumoperitoneum, air embolization, or postprocedural patient discomfort, when compared with air.194,237 Cost-effectiveness of each endoscopic method is also an important factor that may be taken into consideration (Table 3).
TABLE 3 -
Cost of Different Endoscopic Devices Used for Treatment of Sleeve Gastrectomy Leaks
||May require multiple vials
||May require multiple vials
||May require more sutures through the same device
||May require multiple clips
||Usually closure achieved with single clip
||Prices vary, multiple stents with different characteristics available
||May require multiple stents
||Custom made endosponge may lower price
||Other devices for septotomy are also used
|Cariac septal occluder
*Price in US dollar rounded to the nearest tenth. Most commonly used devices in the region are taken into consideration (not all devices and brands are included). Pricing data is based on the most recent publications, personal experience and local market and can vary significantly based on the region, contract, availability, currency, inflation, demand and many other factors. This price may not represent your supplier’s price.
ENDOSCOPIC MANAGEMENT OF ACUTE AND EARLY LEAKS
In the absence of significant fluid collection or after its drainage, acute and early leaks require treatment of the wall defect by exclusion of the defect from ongoing damage or direct closure. Treatment strategy depends on size and characteristics of the defect and expert preference. Sometimes both strategies are necessary and performed sequentially.35 Early closure can prevent further deterioration and fistula development.40
Wall Defect Closure Strategy
Direct closure of the wall defect can be attempted if the aperture is small enough without a fluid collection or after its drainage. Several endoscopic closure devices are available including: through the scope clips (TTS), over the scope clips (OTSC), tissue adhesives, tissue plugs, and endoscopic suturing devices. Appropriate use is mandated based on the size of the defect, local expertise, and endoscopist’s experience.35
Through the Scope Clipping (TTSC)
Through the scope clips are reported as a successful method to manage early leaks.238 However, the data for this particular indication are very limited.239 Clips are successful in treating small defects, especially when other methods are difficult to use due to an inaccessible location.240 TTSC use is limited by leak size, location, and endoscopist experience241 and these clips are usually used in defects <1 cm in size.44,241,242 Once the edges have been adequately approximated, the clip is deployed onto the grasped tissue, and multiple clips can be applied in parallel manner.44 Premature dislodgement of clips and inadequate sealing can occur, requiring repeat treatment.44,238,242 If the tissue is weak, friable, or necrotic, the clip may incise the mucosa without successfully approximating the edges.205,240 Commonly used TTSC include Quick Clip (Olympus America Inc., Center Valley, PA), Resolution Clip (Boston Scientific Inc., Natick, MA), Instinct Clip and TriClip (Cook Medical Inc., Bloomington, IN).242–245 Clips can be combined with other methods.239
The OTSC achieves full-thickness closure of luminal defects.59,246–248 Studies report successful closure in 70% to 100% of SG leaks203,243,249,250 and a meta-analysis revealed overall successful closure in 67% of patients, irrespective of underlying bariatric surgery.243 OTSC can engulf a larger area compared with TTSC (up to 30 mm in size) and imitates a surgical suture in the way it performs.251,252 Suction or additional twin grasper or tissue anchor can be used to pull adequate tissue and approximate edges, by engulfing the whole leak opening into the scope.127,251,253 Predictive criteria for successful closure include early fistula (<7 d); fistulas with less fibrosis, and size 10 to 30 mm. SG leaks are more responsive to successful closure when compared with other etiologies (88.9% vs. overall 61.1%).251 Successful deployment also depends on the ability to maneuver in the narrow working space of a tubular GEJ, size and orientation of defect and surrounding tissue quality.127 Risk factors for clip failure include tissue friability, tissue ischemia, presence of infection, persistence of distal stenosis forming a high-pressure zone at the site of leakage, and difficulty obtaining adequate endoscopic position/view to deploy the clip.59,187 It is unclear whether there is any benefit of using traumatic over atraumatic clips; however, traumatic clips perform better in defects with fibrotic margins.254 Treatment efficacy is operator dependent,249,255 but delayed recurrence of leaks and fistula can occur.40,256 OTSC is significantly more efficient if prior abscess drainage is performed (88.2% vs. 53.8%, P=0.049).251 Once abscess is drained, drains must be removed before fistula closure, as long-term maintenance of drainage perpetuates the fistula.35,251 Fistulas need to be deepithelialized with a cytology brush or with argon plasma coagulation to promote granulation tissue.35 When combined with other endoscopic methods; success is achieved in up to 86% of patients.243,257 Combining OTSC with stent provides additional seal of the defect without compromising oral nutrition, and relief of the reservoir effect (collection of secretions and food that can lead to failure of healing).59,189,253,258 One retrospective study reviewed 106 patients that underwent placement of self-expandable metallic stents (SEMS) versus OTSC for endoscopic perforations or postoperative leakage. Clinical success at the end of follow-up was 46/72 (64%) versus 29/34 (85%) for patients treated by covered SEMS versus OTSC, respectively. Despite higher success with OTSC, the defects treated with OTSC were considerably smaller and there were numerous indications, therefore results of this study should be interpreted with caution.259
Tissue Adhesives and Plugs
Different tissue adhesives were used to treat leaks with data arising predominantly from RYGB patients.
Fibrin sealants contain 2 components, and when mixed, mimic the terminal phase of the clotting cascade producing fibrin monomers that subsequently assemble into a stronger cross-linked fibrin polymer.260 Fibrin sealants (Tisseel VH Fibrin Sealant, Baxter Healthcare); (Beriplast P; Aventis Behring, King of Prussia, Pa.) are used successfully in bariatric patients with RYGB or vertical gastroplasty leaks.261–265 Multiple sessions are required, and success approaches 90% to 100%.243 Fibrin sealant can be injected in the leaking lumen, but if a larger defect is present, the sealant may migrate before coagulation.137 Therefore, submucosal injection around the wall defect, can trigger local edema and narrowing of the defect.137,263 Relative contraindications to fibrin sealant include: presence of adjacent abscess, long fistulous tract and internal orifice diameter >3 cm.263,266
Cyanoacrylate (Histoacryl; B. Braun Melsungen AG, Melsungen, Germany) was used to successfully treat gastropleural, esophagopleural, and enterocutaneous fistulae.267–269 It occludes and seals the defect by rapidly solidifying on contact with weak bases such as water and blood, forming a cast.260 Percutaneous application of cyanoacrylate (Glubran2, GEM, Viareggio, Italy) via a catheter that is slowly retracted was also reported, with success of 80% in patients with adjacent endoscopic stent.270
Fibrin or cyanoacrylate sealants can be ineffective in the presence of a long fistulous tract,203 and use of sealant plugs should be attempted. Surgisis (Cook Biotech Inc., West Lafayette, IA) is an acellular matrix biomaterial derived from porcine small intestine, stimulating proliferation of fibroblasts, resulting in successful closure of leaks and fistulas.271–274 The plug can be inserted endoscopically or percutaneously in case of gastrocutaneous fistula.35 Prior abrasion of the tract using barbed instrument is recommended.35 In lack of success, sealing should be reattempted within days to week.268,271 Overall success in the studies using plugs for fistula closure in bariatric patients reached 80%.
There is one report of a novel EpiFix-dehydrated Human Amnion/Chorion Membrane (dHACM) allograft injected endoscopically to close a leak.275
There are limited data on endoscopic suturing with successful closure in leaks and fistulas.276 This method should be considered in cases where defect size is significant and other methods may not be successful277,278 or when other methods failed. The success was initially reported in RYGB patients. Two cases of leaks following RYGB were successfully treated with an incisionless transoral fastening device that creates plications using polypropylene SerosaFuse fasteners; StomaphyX system (EndoGastric Solutions Inc., Redmond, WA).279 By closing the leak with suture and diverting the gastric content flow, success was achieved in each case and confirmed on repeat endoscopy 3 months afterwards.279 Use of endoscopic suturing device OverStitch system (Apollo Endosurgery Inc., Austin, TX) for treatment of leaks was successful even in patients that had failed other treatments,45,276,280,281 but the overall success rate still needs to be determined (Fig. 6). In a retrospective review, long-term clinical success was only 27% and there was no significant increase in success rate if the leak was closed as a primary or rescue therapy. Long-term clinical success was more likely if the leak was closed ≤30 days of diagnosis as compared with >30 days after diagnosis (44% vs. 0%, respectively),276 indicating its usefulness in mainly treating acute and early leaks. EndoCinch system (CR Bard, Murray Hill, NJ) was used to treat gastrogastic fistulas in RYGB patients. Complete initial closure was achieved in 95% of patients, but reopening occurred in 65% of the successfully treated at an average of 177 days, with part of the failure attributed to the absorbable nature of the sutures.282 None of the fistulas with initial size >20 mm remained closed during the follow-up period compared 32% of fistulas ≤10 mm in diameter, highlighting its use in fistulas with smaller aperture.
Given the need for considerable endoscopic expertise as well as reaching appropriate level on endoscopic suturing learning curve, this method remains exclusivity, and its unique place and role still needs to be identified.269,283,284
Wall Defect Exclusion (Diversion) Strategy
Use of endoluminal stents for acute or early leaks (ie, within 6 wk after SG) is a valid and successful treatment option.10,68,182,285–290 SEMS placement is the most common endoscopic intervention used to manage SG leaks.188 These stents expand radially to its maximal diameter, allowing seal of the leak preventing influx of ongoing secretions as well as providing protection from increased pressure in presence of gastric stenosis, and by that bypassing the defect while healing occurs35,291,292 (Fig. 7). Diversion therapy offers the advantages of early oral alimentation and early discharge, reducing the likelihood of adverse events and costs associated with prolonged hospital stay.35,293–295
The clinical success rate of this procedure, which indicates complete closure of leak or fistula opening, ranges from 65% to 95%.113,203,229,232,296–303 Technical success in deploying the stent ranges from 75% to 100%.304 Data suggest that 80% of patient will require only one round of stenting to achieve clinical success,305 and overall success can be reached in 93% of patients. Prior meta-analyses regarding the use of SEMS in the treatment of postbariatric surgery leaks reported successful closure in 88% to 92% of patients, and successful endoscopic stent removal was achieved in 92% of cases, while stent migration was observed in 17% to 23% of cases.113,215,243 When compared with the other bariatric procedures, SG leaks have lower closure rates due to: larger size of the surface area requiring coverage, difficulties obtaining close apposition with the wall defect and inability to achieve water tightness.35,297 Earlier stenting is associated with higher treatment success,300 and contrariwise the longer the duration, the higher the probability of failure, correlated with development of fibrosis and a chronic fistula tract over time.294,305 Predictors for successful endoscopic stenting of leaks include: male gender, higher prebariatric surgery BMI (BMI 42 vs. BMI 38), and early stenting (25 vs. 49 d).300 Nevertheless, stent placement will not sufficiently manage any concurrent or pre-existing intra-abdominal collections.215 Presence of fluid collection is unfavorable factor in successful treatment with stents, especially when the fluid collection is >5 cm.193
The ideal stent should include anti-migratory mechanisms and should be long enough to cover the incisura/distal end of sleeve.229 The duration of stent presence ranges from 3 to 10 weeks,203,232,297–301,306–308 but some authors report success with <2 weeks of deployment.229,302 Animal studies suggest that 30 days should be adequate time for esophageal healing.309 Stent withdrawal is the only way to know if a fistula persists or has healed.292 Weekly reevaluation of the stent position may detect incipient stent dislodgement and allow easy repositioning or removal.35 Additional stent can be placed in case of stent dislodgement.296,297,310–314
Uncovered SEMS have several limitations that preclude their use in nonmalignant diseases: high risk of bleeding, recurrent strictures, erosions and tissue embedment making their removal traumatic and difficult.315–317 Therefore, covered stents (fully or partially) are currently used. Use of both self-expandable polyester (SEPS) and metal stents (SEMS) have also been reported.35,315 Covered Polyflex (polyester) and Nitinol (nickel-titanium) stents have the advantage of easy implantation and removal but the disadvantage of frequent dislodgement.71 There is less migration with partially covered Nitinol stents, and therefore decreased need for stent replacement.71,293,305,318 Most published studies are retrospective and use different types of stents.319 At this point, there is insufficient data on superiority and effectiveness of different stents in treating leaks, and the choice is left to endoscopist preference.35
Major adverse event (perforation, avulsion, stridor, fistula) rates of self-expandable stent removal after treatment of benign disease is 2.1%, while overall adverse event rate is 10.6%.320 Fully covered SEMS are more successfully removed than partially covered SEMS.320 Migration is an important limiting factor in fully covered stents, occurring in <30% of patients.113,194,239,321 Different strategies to attempt to decrease migration rates with clipping or stent suture fixation are attempted239,322–330 (Fig. 8). Mucosal in-growth at both ends of partially covered stents poses difficulties during stent removal71,293,305,331 which leads to increased risk of bleeding, mucosal stripping, and perforation.35 Stent ingrowth can also cause functional obstruction affecting the leak by increasing intraluminal prosthesis pressure.190 Stent’s radial force itself can cause localized ischemia which can prevent adequate healing and potential increase leak size.190 Rate of complications equals or exceeds 50% of cases if stents remain for more than 6 weeks.332 Therefore, complications can be prevented by removal of the prosthesis within 6 weeks after insertion, without compromising efficacy.332 In occurrence of tissue ingrowth, use of stent-in-stent technique300,331,333,334 or inversion removal technique293 can avoid need for surgical removal.335
Novel stents treating bariatric leaks revealed comparable success and complication rates,59,229,292,301,336,337 but some are not approved by the US Food and Drug Administration (FDA). These alternatives have high profile edges allowing a firmer anchorage, longer length bypassing entire sleeve,203,301,338 and wider diameter facilitating tight seal.339 These stents may be associated with easier endoscopic removal, and minimal number of endoscopic procedures.189,292,295,336,337,340–345 These stents include: MEGASTENT and Niti-S Beta (TaeWoong Medical Industries); HANAROSTENT (Olympus) and GASTROSEAL (M.I.Tech, Seoul, South Korea) (Fig. 9). Some authors report their use as part of combination therapy, along with external drainage.198,341 Because of large size, these stents are sometimes difficult to tolerate causing nausea, vomiting, abdominal pain, and requiring early removal. Development of duodenal bulb ulcers is also reported; where stent’s distal edge is anchored, making these stents not used as frequently.189,301,344,346 Large-scale, randomized, prospective studies to compare conventional and tailored stents are needed.203
Biodegradable stents were recently used with satisfactory results. They do not require repeat endoscopy for extraction, but degradation before leak closure can occur.347,348
Stenting can also be combined with some of the techniques of wall defect closure (eg, over the scope clips), but success varies, and further studies are needed to evaluate whether combined techniques are superior.59,198,341,345,349
Wall Drainage Strategy
Transfistulary stenting (discussed below) is also a feasible option used as a sole therapeutic method in patients with acute or early leaks with adjacent fluid collection not drained by other methods.187 Few studies have reported successful treatment of these leaks with the use of transgastric stents, with 90% of patients having acute or early leaks.194,350 This strategy is discussed below.
ENDOSCOPIC MANAGEMENT OF CHRONIC AND LATE LEAKS
An approach of drainage with endoscopic debridement is recommended for chronic or late leaks with or without walled off collections.10,35,237,351 Esophageal stenting and closure techniques have limited utility in this situation68,193 as leak transforms into fistula by fibrosis and epithelialization.35,299,300,352 Simple fluid collections can be drained without the need of debridement. However, presence of any foreign material needs to be removed from the leak cavity to promote healing.353–355 Dilation of the pylorus and distal sleeve is important for management of chronic leaks since presence of stenosis impedes healing and further perpetuates the leak.127,353–355 Aggressive dilation has to be carried out before or during the period of endoscopic internal drainage (EID).190
When a necrotic collection develops, drainage alone may not be effective due to presence of thick solid material.187,232,235 Endoscopic or surgical debridement is required before drainage, to enable adequate drainage of the semiliquid material present.232 Endoscopic mechanical debridement follows similar principles as endoscopic debridement of pancreatic collections and can be performed using a snare, net, or basket.356,357 Dormia basket (CooK Medical, Winston-Salem, NC) has been reported as successful for debridement of necrotic tissue and/or septations.232 Saline lavage followed by injection of antibiotics (amikacin 500 mg) into the cystic cavity is reported in certain cases.232 Patients that required debridement should be supplemented by drainage of the collection after debridement.232,235
Endoscopic Transluminal Drainage
Nasocystic catheter (5 to 7 Fr Nasal Biliary or 5 Fr Nasal Pancreatic Drainage Set; Cook Medical) is indicated for presence of large collection that would require repeated flushing to eliminate pus and debris.193,350 It is placed in similar fashion as for pancreatic fluid collections drainage,232,356,358,359 remains in place for 3 to 7 days356,358,359 and is usually combined with transfistulary stents.193,350 Continuous irrigation with 1500 mL saline solution per day is used in pancreatic collections, but data are limited for anastomotic collections.356 This catheter can lead to significant discomfort, especially with the use of another tube for concurrent enteral feeding.360 Also, reduction in pressure within the perigastric collection, may hamper internal drainage of material into the gastric lumen.187
Transfistulary stenting, an EID is a safe first-line treatment of SG leaks with fluid collections as well as a salvage treatment when other endoscopic techniques fail.35,214,350,361,362 However, other methods can achieve internal drainage as well, making this term confusing. Some authors have adopted transfistulary stenting as the only endoscopic modality of treatment of leaks after LSG.190,291 Clinical success varies in the range of 70% to 85%.190,215,350,362,363 In a systematic review including 11 studies with total of 681 patients, successful leak closure was noted in 85% when used as a first-line treatment and 78% as a rescue therapy.363 Their success was reported in both acute/early and chronic/late leaks.193,194,350
Using double-pigtail stents, leak drainage is achieved similarly as pseudocyst drainage. The stents keep the fistula tract between the gastric lumen and the infected paragastric space open, with progressive reduction of the collection and conversion into a “virtual” cavity that is only occupied by pigtail loops.35,350,364 In addition, the pigtail stent can potentially act as a foreign body in the dead space, promoting tissue granulation190,194 and reepithelialization.35,194,291 Plastic double pigtail stents (7 to 10 Fr Zimmon or Solus, Cook Medical; 7 to 10 Fr Advanix, Boston Scientific; 8.5 Fr Endo-Flex, Voerde) are endoscopically placed alone or along with a nasocystic catheter.350 Some authors believe that nasocystic catheter should be avoided long-term because it reduces interluminal pressure, slowing down internal drainage.187 Therefore, external drains and nasocystic catheter should be removed, or used solely for intermittent flushing while remaining clamped during the interim period.187 The double-pigtail stent is left in situ, to facilitate the continuous outflow of the remaining necrotic and purulent material and is exchanged every 4 to 6 weeks until the fluid collection is completely drained.190,194,356 Some authors advise against routine stent exchange unless necrosectomy is also performed.187 Removal should be performed as soon as clinical/radiologic resolution is seen.187 Occasionally, a small residual cavity resembling pseudodiverticulum may form at the end of the drainage process without any clinical significance, and not requiring closure.187,194,365 If cyst orifice is not clearly identified, endoscopic ultrasound can assist in drainage, just like pancreatic pseudocysts.35,189,194,214,366,367 This method reduces the need of external drainage (surgical/radiologic), thus reducing interval time between diagnosis and treatment, complications, and costs.195 Patients with a unique and well-circumscribed collection are good candidates for this treatment, but complex disorganized, multiple, or uncontained leakages may resist internal drainage and require surgical intervention.187,350 Transfistulary stenting for noncontained collections should be supplemented by external drain that led to 93% success at 1-year follow-up by one study.195 This approach needs to be compared to surgery alone.195 Aggressive dilation of downstream stenosis is required to reduce intragastric pressure and ultimately, reverse pressures with spontaneous drainage of the debris into gastric lumen.187,194,196,368,369 Oral nutrition is recommended since the pressure gradient should keep food away from the perigastric cavity.187 In cases of severe gastric stenosis where high intragastric pressure is present or in presence of large leak orifice >1 to 2 cm where pigtail stent migration is imminent, placement of a fully covered stent with or without double pigtail stent may be the appropriate strategy.196,369 Over the scope clip has been successfully used as an adjunct to transfistulary (transluminal internal) drainage, as a final closure of the leak after drainage with double pigtail stent for 4 to 6 weeks.291 Mean leak healing time is 118 days (range: 5 to 227 d), which may deter endoscopists from its routine use and may render this method economically not feasible.291,363,368 Common complications include stent migration into the perigastric cavity or gastric lumen and ulcerations in the gastric wall.190,291,350,370,371
A retrospective study compared closure/diversion and internal drainage strategies for treatment of chronic leaks. Closure/diversion strategy involved placement of covered metal stent and/or clipping or glue. Internal drainage strategy involved placement of double pigtail stent within the cavity with or without nasocystic drain. Higher leak resolution was achieved in patients undergoing internal drainage compared with patients undergoing closure/diversion (86% vs. 63%, respectively). Patients that failed closure/diversion also underwent EID, with a success rate of 82%.193 In addition, transluminal stenting may be more cost-effective compared with covered stents (€20,024 vs. €24,916; P=0.018, in one study).63
Endoscopic vacuum-assisted closure (EVAC) is a technique where endoscopically inserted sponge absorbs fluid leading to rapid control of sepsis, reducing risk of contamination/superinfection, and accelerating formation of granulation tissue.203,206,372–377 It uses the same principles described in open vacuum-assisted wound closure.378 Rapid and significant decline in leukocytosis, CRP levels and APACHE II score was noted after vacuum-assisted closure, confirming rapid control of sepsis by efficient drainage of infected wound cavity.372 In case of failure, endoscopic vacuum therapy (EVT) does not jeopardize surgical repair.206 EVAC is considered as first line and salvage therapy in patients who fail other endoscopic methods.40,379
Endo-SPONGE system (B. Braun Melsungen AG, Melsungen, Germany) or an open pore polyurethane sponge (VivanoMed Foam, Paul Hartmann AG, Heidenheim, Germany) has been used.206,380 The sponge can be inserted in the cavity (intracavitary vacuum therapy) in accessible leakages with a large opening (≥9 mm), or at the level of the esophageal wall defect (intraluminal vacuum therapy), if the orifice is too small to accommodate the sponge.360 The sponge is connected to an external vacuum device through a nasocystic or nasogastric catheter (Fig. 10). Suction is applied using a continuous negative pressure of 70 to 125 mm Hg.206,360,372,380 After 2 to 5 days, cavity is reevaluated, and sponge replaced until cavity is closed or the wound cavity becomes small, contained, and lined by granulation tissue.374,375 This technique results in negative pressure at the leak site, necessitating a feeding jejunostomy or total parenteral nutrition.187 Mean number of sponge insertions in one study was 6, where sponges were changed every 3.5 days.381 EVAC may be combined with placement of endoluminal stent to improve vacuum force and maintain esophageal passage,374,382 or in the presence of persistent wall defects despite drainage.380
Its clinical success ranges from 84% to 100%,360,372,375,380,383,384 but data are limited and come from treatment of nonbariatric and non-SG leaks and perforations.360,372 In SG leaks, successful closure has been documented in early and late leaks, with time interval between bariatric surgery and endoscopic treatment of 32 and 61 days, respectively.375,383 Two retrospective studies comparing EVAC to endoluminal stenting in esophageal leaks revealed success of 84% and 93% versus 54% and 63%, respectively.360,385 Another study revealed lower mortality using EVAC compared with stenting.386 These are retrospective studies of endoscopic closure of esophageal intrathoracic leaks and need to be evaluated cautiously.
The need for multiple endoscopic procedures and prolonged hospitalization stay makes EVAC treatment challenging,189,206,360,374 with some studies reporting success after average of 50 days EVAC therapy.375 Preprocedural preparation with placement of a suitable sponge can be time consuming, but procedure duration improves rapidly with increasing experience.206,360 Preassembled EVT sets for the upper GI tract fitting different cavities and endoluminal diameters are increasingly offered commercially, further reducing processing time.206 In addition, the erosive effect of the vacuum can cause severe hemorrhage if placed adjacent to vascular structures, but this was reported in 2 cases, and the underlying significance and correlation needs to be determined.360,372,387 Nevertheless, its use needs to be weighted carefully in cases of close contact to major thoracic or abdominal vascular structures.206 Once case of pancreatitis was reported, correlating it to the EVT.375
Septotomy or fenestration is a technique of cutting the pseudoseptum between perigastric cavity and gastric lumen using needle knife, cutting knife, or APC probe, to facilitate drainage.55,200,289,353–355,388–395 It addresses the pressure gradient that drives gastric contents from the lumen into perigastric collection, and by completely exposing the leak cavity, it equalizes the interluminal pressures391 (Fig. 11). This technique acts like endoscopic treatment of Zenker’s diverticulum and allows healing by secondary intention and epithelialization.55 It is only performed if a septum between perigastric cavity and gastric lumen is identified.41 Sleeve dilation is required in presence of downstream stenosis or axis deviation,41,200 which reduces intragastric pressure. Bleeding occurs more frequently with the needle-knife technique due to lack of coagulative effect.55 APC generates high current densities and effectively ablates the septal tissue, while simultaneously coagulating the margins to limit bleeding.55 On the basis of the available case reports and case series, its effectiveness approaches 100%. Sometimes repeated septotomy is required, and some cases require up to 11 attempts, with average number of procedures of 2 to 5.55,354,355 Repeated therapy is performed as necessary, with more pseudoseptum being cut each time.187
Cardiac Septal Occluder Device
Cardiac septal occluder (CSDO) device was recently reported to successfully treat chronic and late leaks.233 Amplatzer CSDO (St. Jude Medical, Plymouth, Minn) is a shape-memory, self-expanding double-disk (double umbrella) closure device made of nitinol and interwoven polyester, which promotes in-growth while sealing the fistula tract.396 These features may allow approach to fistulas with irregular margins, epithelialized tracts, and edematous or scarred tissue.396 The device can reposition as needed before final deployment, and even then, can be removed endoscopically, reassembled and placed again, until final satisfactory position is achieved.233 Attempts to treat acute and early leaks is less successful and recurrence of leaks are common, requiring replacement and upsizing of the occluder. Overall treatment success was 62% for acute/early leaks and 97% for late/chronic leaks.233 Presence of late and chronic leaks is a significand predictor of treatment success.233 More studies are needed to define size and type of occlude device, length of fistula that can be closed and potential adverse events. Since this represents an occlusion device, drainage of adjacent fluid collection based on the principles described above is still necessary.233
Sparse case reports have also identified the success of ventricular or atrial septal occluder or vascular plug use in different types of gastrointestinal leaks and fistulas with similar mechanism of action.387,397–421
DILATION OF DISTAL STENOSIS
Postoperative stenosis is a known complication of bariatric surgery203 with incidence of 1% to 4%422–424 and a major contributing factor to leak development.5,126 Its incidence is reported as 0.5% to 3.5%.9,46,424,425
Incisura angularis followed by GEJ are sites with greatest stenosis potential.77 Stenosis typically occurs due to calibration of the sleeve over a tube that is too narrow or oversewing of the staple line.77 Two types are recognized in the literature. Functional stenosis (helix stenosis) is abnormal rotation, kinking and twisting of the sleeve, with the ability of the endoscope to traverse the stenosis.67,101,102,426 In mechanical stenosis, passage of the endoscope is difficult or impossible67,102 due to overtraction of the greater curvature during stapling or hematomas that may organize into scar tissue.67 The elevated intraluminal pressure due to stenosis is a major contributing factor to a higher leak rate,5,126 therefore prompt identification and treatment is essential.
Postoperative imaging does not predict development of stenosis, as initial normal appearance of the sleeve is frequently observed.101,427–432 Therefore, if suspicion of stenosis is present, prompt endoscopic evaluation and treatment is required, since early endoscopic treatment (within 90 d after surgery) is more effective than late, which may lead to revisional surgery.203,433 Current treatments for sleeve stenosis include: balloon dilation and endoluminal stenting.
Since the introduction of through-the-scope (TTS) endoscopy, endoscopic balloon dilation of stenoses became established as an effective and safe therapeutic tool.203 Some require repeat dilation, ranging from 2 to 4 sessions and even up to 7 sessions (Fig. 12). The success rate which indicates resolution of obstructive symptoms and passage of the endoscope without disturbance exceeds 90% in proximal and 70% in distal stenoses.203,423–434 However, serious complications including perforation are reported in 2% to 5% of cases. Long-segment stenoses that do not respond to endoscopic techniques may ultimately require conversion to RYGB.424 Controlled radial expansion balloon (Boston Scientific Corporation, Marlborough, MA) is effective when dilated 15 to 20 mm in diameter for most strictures.77,424,435 However, a larger, achalasia balloon dilator Rigiflex II Balloon (Boston Scientific),425,434 is required in cases of treatment-refractory strictures.77,425,436 Gradual increase in balloon size by 5mm every third dilation (max of 40 mm) has been adopted as a protocol for treatment of these stenoses.423 Other experts reported success with endoscopic needle cuts in four quadrants after dilation for refractory patients.426
Placement of a stent at the stenosis site is another option that can treat both stenosis and leak simultaneously.47,293,295,310,425,437,438 It can be used along balloon dilation as well.425 The principles of stent placement are described above. It remains uncertain which method is more effective, and most recent data suggest that endoluminal stents and pneumatic dilation are more effective than TTS balloon.436
Leaks remain a major complication of SG and are associated with significant morbidity, prolonged hospital stay, and surgical failure. Successful management requires close collaboration between the bariatric surgeon, gastroenterologist, interventional radiologist, infectious disease specialist, and nutritionist.
Every case should be addressed uniquely based on clinical presentation, location, complexity and onset. Despite this, some general rules need to be applied: commencement of early intravenous hydration, antibiotics, and nutrition. With presence of fluid collection, successful drainage is required before attempting or during endoscopic treatment.
In the absence of septic shock or clinical instability, endoscopic management should be attempted for a minimum of 3 to 6 months. At this point there are sparse data to favor specific endoscopic methods, and the approach depends on leak location, onset, and personal experience. Closure and diversion strategies are predominantly reserved for acute and early leaks, while internal drainage strategies are used mainly for late and chronic leaks. The latter can be performed in early leaks as well, if a fluid collection is present and percutaneous drainage was not attempted. In the presence of distal stenosis, treatment with balloon dilation or stenting is required to facilitate healing and prevent leak recurrence. Ultimately, unsuccessful endoscopic treatment of leak after 3 to 6 months requires surgical revision.
As the popularity of SG grows, it is important that all gastroenterologists be familiar with this procedure and its complications since its management is mainly driven by the gastroenterologist and their endoscopic capability. Success rates in tackling SG leaks depends on the center’s expertise, and such cases should be managed at centers with high volume and expertise in endoscopic techniques and surgical revisions to minimize morbidity and improve outcomes.
1. Spaniolas K, Kasten KR, Brinkley J, et al. The changing bariatric surgery landscape in the USA. Obes Surg. 2015;25:1544–1546.
2. Benaiges D, Más-lorenzo A, Goday A, et al. Laparoscopic sleeve gastrectomy: more than a restrictive bariatric surgery procedure. World J Gastroenterol. 2015;21:11804–11814.
3. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23:427–436.
4. Estimate of Bariatric Surgery Numbers, 2011-2017. ASMBS Professional Resource Center Volume 2019. Gainesville, FL: ASMBS; 2018.
5. Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg. 2008;18:1083–1088.
6. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–863.
7. Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124–1128.
8. Shi X, Karmali S, Sharma AM, et al. A review of laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg. 2010;20:1171–1177.
9. 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.
10. Schulman AR, Thompson CC. Complications of bariatric surgery: what you can expect to see in your GI practice. Am J Gastroenterol. 2017;112:1640–1655.
11. Ramón JM, Salvans S, Crous X, et al. Effect of Roux-en-Y gastric bypass vs sleeve gastrectomy on glucose and gut hormones: a prospective randomised trial. J Gastrointest Surg. 2012;16:1116–1122.
12. Juodeikis Ž, Brimas G. Long-term results after sleeve gastrectomy: a systematic review. Surg Obes Relat Dis. 2017;13:693–699.
13. Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254:410–420.
14. Kumar SB, Hamilton BC, Wood SG, et al. Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? A comparison of 30-day complications using the MBSAQIP data registry. Surg Obes Relat Dis. 2018;14:264–269.
15. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–781.
16. Abbatini F, Rizzello M, Casella G, et al. Long-term effects of laparoscopic sleeve gastrectomy, gastric bypass, and adjustable gastric banding on type 2 diabetes. Surg Endosc. 2010;24:1005–1010.
17. Alvarenga ES, Lo menzo E, Szomstein S, et al. Safety and efficacy of 1020 consecutive laparoscopic sleeve gastrectomies performed as a primary treatment modality for morbid obesity. A single-center experience from the metabolic and bariatric surgical accreditation quality and improvement program. Surg Endosc. 2016;30:2673–2678.
18. Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2016;12:750–756.
19. Singla V, Aggarwal S, Garg H, et al. Outcomes in super obese patients undergoing laparoscopic sleeve gastrectomy. J Laparoendosc Adv Surg Tech A. 2018;28:256–262.
20. Gill RS, Birch DW, Shi X, et al. Sleeve gastrectomy and type 2 diabetes mellitus: a systematic review. Surg Obes Relat Dis. 2010;6:707–713.
21. Braghetto I, Csendes A, Lanzarini E, et al. Is laparoscopic sleeve gastrectomy an acceptable primary bariatric procedure in obese patients? Early and 5-year postoperative results. Surg Laparosc Endosc Percutan Tech. 2012;22:479–486.
22. Benaiges D, Flores-le-roux JA, Pedro-botet J, et al. Impact of restrictive (sleeve gastrectomy) vs hybrid bariatric surgery (Roux-en-Y gastric bypass) on lipid profile. Obes Surg. 2012;22:1268–1275.
23. Hoyuela C. Five-year outcomes of laparoscopic sleeve gastrectomy as a primary procedure for morbid obesity: a prospective study. World J Gastrointest Surg. 2017;9:109–117.
24. Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome. Ann Surg. 2005;242:610–617.
25. Ali M, El chaar M, Ghiassi S, et al. American Society for Metabolic and Bariatric Surgery updated position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis. 2017;13:1652–1657.
26. Fischer L, Wekerle AL, Bruckner T, et al. BariSurg trial: sleeve gastrectomy versus Roux-en-Y gastric bypass in obese patients with BMI 35-60 kg/m(2)—a multi-centre randomized patient and observer blind non-inferiority trial. BMC Surg. 2015;15:87.
27. Chang SH, Freeman NLB, Lee JA, et al. Early major complications after bariatric surgery in the USA, 2003-2014: a systematic review and meta-analysis. Obes Rev. 2018;19:529–537.
28. Zellmer JD, Mathiason MA, Kallies KJ, et al. Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Am J Surg. 2014;208:903–910.
29. Lainas P, Dammaro C, Gaillard M, et al. Safety and short-term outcomes of laparoscopic sleeve gastrectomy for patients over 65 years old with severe obesity. Surg Obes Relat Dis. 2018;14:952–959.
30. Altieri MS, Pryor A, Bates A, et al. Bariatric procedures in adolescents are safe in accredited centers. Surg Obes Relat Dis. 2018;14:1368–1372.
31. Moulla Y, Lyros O, Blüher M, et al. Feasibility and safety of bariatric surgery in high-risk patients: a single-center experience. J Obes. 2018;2018:7498258.
32. Ruiz-cota P, Bacardí-gascón M, Jiménez-cruz A. Long-term outcomes of metabolic and bariatric surgery in adolescents with severe obesity with a follow-up of at least 5 years: a systematic review. Surg Obes Relat Dis. 2019;15:133–144.
33. Daigle CR, Brethauer SA, Tu C, et al. Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcomes. Surg Obes Relat Dis. 2018;14:652–657.
34. Garg H, Aggarwal S, Misra MC, et al. Mid to long term outcomes of laparoscopic sleeve gastrectomy in Indian population: 3-7 year results—a retrospective cohort study. Int J Surg. 2017;48:201–209.
35. Souto-rodríguez R, Alvarez-sánchez MV. Endoluminal solutions to bariatric surgery complications: a review with a focus on technical aspects and results. World J Gastrointest Endosc. 2017;9:105–126.
36. Morino M, Toppino M, Forestieri P, et al. Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry. Ann Surg. 2007;246:1002–1007.
37. Peel AL, Taylor EW. Proposed definitions for the audit of postoperative infection: a discussion paper. Surgical Infection Study Group. Ann R Coll Surg Engl. 1991;73:385–388.
38. Goenka MK, Goenka U. Endotherapy of leaks and fistula. World J Gastrointest Endosc. 2015;7:702–713.
39. Kumar N, Thompson CC. Endoscopic therapy for postoperative leaks and fistulae. Gastrointest Endosc Clin N Am. 2013;23:123–136.
40. Bemelman WA, Baron TH. Endoscopic management of transmural defects, including leaks, perforations, and fistulae. Gastroenterology. 2018;154:1938–1946 e1.
41. De moura DTH, Sachdev AH, Thompson CC. Endoscopic full-thickness defects and closure techniques. Curr Treat Options Gastroenterol. 2018;16:386–405.
42. Kumar N, Larsen MC, Thompson CC. Endoscopic management of gastrointestinal fistulae. Gastroenterol Hepatol (N Y). 2014;10:495–452.
43. Falconi M, Pederzoli P. The relevance of gastrointestinal fistulae in clinical practice: a review. Gut. 2001;49(suppl 4):iv2–iv10.
44. Singh RR, Nussbaum JS, Kumta NA. Endoscopic management of perforations, leaks and fistulas. Transl Gastroenterol Hepatol. 2018;3:85.
45. Ge PS, Thompson CC. The use of the overstitch to close perforations and fistulas. Gastrointest Endosc Clin N Am. 2020;30:147–161.
46. Emile SH, Elfeki H, Elalfy K, et al. Laparoscopic sleeve gastrectomy then and now: an updated systematic review of the progress and short-term outcomes over the last 5 years. Surg Laparosc Endosc Percutan Tech. 2017;27:307–317.
47. Kim J, Azagury D, Eisenberg D, et al. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015;11:739–748.
48. Alizadeh RF, Li S, Inaba C, et al. Risk factors for gastrointestinal leak after bariatric surgery: MBASQIP analysis. J Am Coll Surg. 2018;227:135–141.
49. Stroh C, Birk D, Flade-kuthe R, et al. Results of sleeve gastrectomy-data from a nationwide survey on bariatric surgery in Germany. Obes Surg. 2009;19:632–640.
50. Burgos AM, Braghetto I, Csendes A, et al. Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg. 2009;19:1672–1677.
51. Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg. 2006;16:1450–1456.
52. 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;10:713–723.
53. Liu N, Cusack MC, Venkatesh M, et al. 30-Day outcomes after intraoperative leak testing for bariatric surgery patients. J Surg Res. 2019;242:136–144.
54. Benedix F, Benedix DD, Knoll C, et al. Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity? Obes Surg. 2014;24:1610–1616.
55. Mahadev S, Kumbhari V, Campos JM, et al. Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections. Endoscopy. 2017;49:504–508.
56. Sakran N, Goitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc. 2013;27:240–245.
57. Spyropoulos C, Argentou MI, Petsas T, et al. Management of gastrointestinal leaks after surgery for clinically severe obesity. Surg Obes Relat Dis. 2012;8:609–615.
58. Saliba C, Nicolas G, Diab S, et al. Gastrobronchial fistula following a laparoscopic sleeve gastrectomy. Am J Case Rep. 2019;20:31–35.
59. Shehab HM, Hakky SM, Gawdat KA. An endoscopic strategy combining mega stents and over-the-scope clips for the management of post-bariatric surgery leaks and fistulas (with video). Obes Surg. 2016;26:941–948.
60. Iannelli A, Treacy P, Sebastianelli L, et al. Perioperative complications of sleeve gastrectomy: review of the literature. J Minim Access Surg. 2019;15:1–7.
61. Moszkowicz D, Arienzo R, Khettab I, et al. Sleeve gastrectomy severe complications: is it always a reasonable surgical option? Obes Surg. 2013;23:676–686.
62. Bransen J, Gilissen LP, Van rutte PW, et al. Costs of leaks and bleeding after sleeve gastrectomies. Obes Surg. 2015;25:1767–1771.
63. Cosse C, Rebibo L, Brazier F, et al. Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy. Br J Surg. 2018;105:570–577.
64. Timsit G, Johanet H. Medico-legal claims in bariatric surgery in France between 2010 and 2015. J Visc Surg. 2019;156(suppl 1):S51–S55.
65. Marie L, Masson C, Gaborit B, et al. An experimental study of intraluminal hyperpressure reproducing a gastric leak following a sleeve gastrectomy. Obes Surg. 2019;29:2773–2780.
66. Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obes Surg. 2004;14:1290–1298.
67. Silecchia G, Iossa A. Complications of staple line and anastomoses following laparoscopic bariatric surgery. Ann Gastroenterol. 2018;31:56–64.
68. Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8–19.
69. Iossa A, Abdelgawad M, Watkins BM, et al. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbecks Arch Surg. 2016;401:757–766.
70. Hussain A, Vasas P, Kirk K, et al. Etiology of leaks following sleeve gastrectomy: current evidence. Surg Laparosc Endosc Percutan Tech. 2017;27:119–122.
71. Deitel M, Gagner M, Erickson AL, et al. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7:749–759.
72. Derici S, Atila K, Bora S. The effect of the cartridge used in laparoscopic sleeve gastrectomy on the development of a staple-line leak. Am Surg. 2018;84:1499–1503.
73. Barski K, Binda A, Kudlicka E, et al. Gastric wall thickness and stapling in laparoscopic sleeve gastrectomy—a literature review. Wideochir Inne Tech Maloinwazyjne. 2018;13:122–127.
74. El moussaoui I, Limbga A, Mehdi A. Staple line reinforcement during sleeve gastrectomy with a new type of reinforced stapler. Minerva Chir. 2018;73:127–132.
75. Tulelli B, Loi P, Van vyve E, et al. Risk factors of perioperative morbimortality after laparoscopic sleeve gastrectomy: a club coelio multicenter study. Acta Chir Belg. 2018;118:94–98.
76. Warner DL, Sasse KC. Technical details of laparoscopic sleeve gastrectomy leading to lowered leak rate: discussion of 1070 consecutive cases. Minim Invasive Surg. 2017;2017:4367059.
77. Mathus-vliegen EM. The cooperation between endoscopists and surgeons in treating complications of bariatric surgery. Best Pract Res Clin Gastroenterol. 2014;28:703–725.
78. Shikora SA, Mahoney CB. Clinical benefit of gastric staple line reinforcement (slr) in gastrointestinal surgery: a meta-analysis. Obes Surg. 2015;25:1133–1141.
79. Coskun H, Yardimci E. Effects and results of fibrin sealant use in 1000 laparoscopic sleeve gastrectomy cases. Surg Endosc. 2017;31:2174–2179.
80. Sepúlveda M, Astorga C, Hermosilla JP, et al. Staple line reinforcement in laparoscopic sleevegastrectomy: experience in 1023 consecutive cases. Obes Surg. 2017;27:1474–1480.
81. Lynn W, Ilczyszyn A, Aguilo R, et al. Standardised sleeve gastrectomy without reinforcement. JSLS. 2018;22:e2018.00015.
82. El chaar M, Stoltzfus J. Assessment of sleeve gastrectomy surgical technique: first look at 30-day outcomes based on the MBSAQIP Database. J Am Coll Surg. 2018;227:564–572.
83. Cunningham-hill M, Mazzei M, Zhao H, et al. The impact of staple line reinforcement utilization on bleeding and leak rates following sleeve gastrectomy for severe obesity: a propensity and case-control matched analysis. Obes Surg. 2019;29:2449–2463.
84. Gagner M, Kemmeter P. Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review. Surg Endosc. 2020;34:396–407.
85. Ozdenkaya Y, Olmuscelik O, Basim P, et al. The effect of fibrin glue in preventing staple-line leak after sleeve gastrectomy. An experimental study in rats. Acta Cir Bras. 2019;34:e201900801.
86. Siddiq G, Aziz W, Khizar S, et al. Laparoscopic sleeve gastrectomy: to suture or not to suture staple line. Cureus. 2018;10:e2992.
87. Usta S, Karabulut K. Effect of fibrin glue or suture on leakage in patients undergoing laparoscopic sleeve gastrectomy. Niger J Clin Pract. 2018;21:1209–1212.
88. Demeusy A, Sill A, Averbach A. Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015-2016 PUF. Surg Obes Relat Dis. 2018;14:1454–1461.
89. Guerrier JB, Mehaffey JH, Schirmer BD, et al. Reinforcement of the staple line during gastric sleeve: a comparison of buttressing or oversewing, no reinforcement—a single-institution study. Am Surg. 2018;84:690–694.
90. Hany M, Ibrahim M. Comparison between stable line reinforcement by barbed suture and non-reinforcement in sleeve gastrectomy: a randomized prospective controlled study. Obes Surg. 2018;28:2157–2164.
91. Wang H, Lu J, Feng J, et al. Staple line oversewing during laparoscopic sleeve gastrectomy. Ann R Coll Surg Engl. 2017;99:509–514.
92. Cesana G, Cioffi S, Giorgi R, et al. Proximal leakage after laparoscopic sleeve gastrectomy: an analysis of preoperative and operative predictors on 1738 consecutive procedures. Obes Surg. 2018;28:627–635.
93. Bellanger DE, Greenway FL. Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg. 2011;21:146–150.
94. Casella G, Soricelli E, Rizzello M, et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg. 2009;19:821–826.
95. Frattini F, Delpini R, Inversini D, et al. Gastric leaks after sleeve gastrectomy: focus on pathogenetic factors. Surg Technol Int. 2017;31:123–126.
96. Gagner M. Leaks after sleeve gastrectomy are associated with smaller bougies: prevention and treatment strategies. Surg Laparosc Endosc Percutan Tech. 2010;20:166–169.
97. Parikh M, Issa R, Mccrillis A, et al. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg. 2013;257:231–237.
98. Berger ER, Clements RH, Morton JM, et al. The impact of different surgical techniques on outcomes in laparoscopic sleeve gastrectomies: the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Ann Surg. 2016;264:464–473.
99. Elgeidie A, Elhemaly M, Hamdy E, et al. The effect of residual gastric antrum size on the outcome of laparoscopic sleeve gastrectomy: a prospective randomized trial. Surg Obes Relat Dis. 2015;11:997–1003.
100. Obeidat F, Shanti H, Mismar A, et al. The magnitude of antral resection in laparoscopic sleeve gastrectomy and its relationship to excess weight loss. Obes Surg. 2015;25:1928–1932.
101. Agnihotri A, Barola S, Hill C, et al. An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy. Obes Surg. 2017;27:2628–2636.
102. Manos T, Nedelcu M, Cotirlet A, et al. How to treat stenosis after sleeve gastrectomy. Surg Obes Relat Dis. 2017;13:150–154.
103. Noel P, Nedelcu M, Gagner M. Impact of the surgical experience on leak rate after laparoscopic sleeve gastrectomy. Obes Surg. 2016;26:1782–1787.
104. Varban OA, Sheetz KH, Cassidy RB, et al. Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study. Surg Obes Relat Dis. 2017;13:560–567.
105. Goldberg I, Yang J, Park J, et al. Surgical trainee impact on bariatric surgery safety. Surg Endosc. 2019;33:3014–3025.
106. Varban OA, Thumma JR, Finks JF, et al. Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study. Surg Endosc. 2019;33:895–903.
107. Frohman HA, Rychahou PG, Li J, et al. Development of murine bariatric surgery models: lessons learned. J Surg Res. 2018;229:302–310.
108. Liu JB, Ban KA, Berian JR, et al. Concurrent bariatric operations and association with perioperative outcomes: registry based cohort study. BMJ. 2017;358:j4244.
109. Inaba CS, Koh CY, Sujatha-bhaskar S, et al. Operative time as a marker of quality in bariatric surgery. Surg Obes Relat Dis. 2019;15:1113–1120.
110. Major P, Wysocki M, Pędziwiatr M, et al. Risk factors for complications of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Int J Surg. 2017;37:71–78.
111. Fazl alizadeh R, Li S, Inaba CS, et al. Robotic versus laparoscopic sleeve gastrectomy: a MBSAQIP analysis. Surg Endosc. 2019;33:917–922.
112. Husain F, Jeong IH, Spight D, et al. Risk factors for early postoperative complications after bariatric surgery. Ann Surg Treat Res. 2018;95:100–110.
113. Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis. Gastrointest Endosc. 2012;75:287–293.
114. Creange C, Sethi M, Fielding G, et al. The safety of laparoscopic sleeve gastrectomy among diabetic patients. Surg Endosc. 2017;31:907–911.
115. Lin X, Li J, Chen W, et al. Diabetes and risk of anastomotic leakage after gastrointestinal surgery. J Surg Res. 2015;196:294–301.
116. Fernandez AZ, Demaria EJ, Tichansky DS, et al. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc. 2004;18:193–197.
117. Mazzei M, Zhao H, Edwards MA. Perioperative outcomes of bariatric surgery in the setting of chronic steroid use: an MBSAQIP database analysis. Surg Obes Relat Dis. 2019;15:926–934.
118. Hefler J, Dang J, Modasi A, et al. Effects of chronic corticosteroid and immunosuppressant use in patients undergoing bariatric surgery. Obes Surg. 2019;29:3309–3315.
119. Gaillard M, Tranchart H, Maitre S, et al. Preoperative detection of sarcopenic obesity helps to predict the occurrence of gastric leak after sleeve gastrectomy. Obes Surg. 2018;28:2379–2385.
120. Dhar VK, Hanseman DJ, Watkins BM, et al. What matters after sleeve gastrectomy: patient characteristics or surgical technique. Surgery. 2018;163:571–577.
121. Livingston EH, Huerta S, Arthur D, et al. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg. 2002;236:576–582.
122. Weiner RA, El-sayes IA, Theodoridou S, et al. Early post-operative complications: incidence, management, and impact on length of hospital stay. A retrospective comparison between laparoscopic gastric bypass and sleeve gastrectomy. Obes Surg. 2013;23:2004–2012.
123. Elariny H, González H, Wang B. Tissue thickness of human stomach measured on excised gastric specimens from obese patients. Surg Technol Int. 2005;14:119–124.
124. Trelles N, Gagner M, Palermo M, et al. Gastrocolic fistula after re-sleeve gastrectomy: outcomes after esophageal stent implantation. Surg Obes Relat Dis. 2010;6:308–312.
125. Abou rached A, Basile M, El masri H. Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol. 2014;20:13904–13910.
126. Márquez MF, Ayza MF, Lozano RB, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20:1306–1311.
127. Aly A, Lim HK. The use of over the scope clip (OTSC) device for sleeve gastrectomy leak. J Gastrointest Surg. 2013;17:606–608.
128. Nedelcu M, Danan M, Noel P, et al. Surgical management for chronic leak following sleeve gastrectomy: review of literature. Surg Obes Relat Dis. 2019;15:1844–1849.
129. Rawlins L, Rawlins MP, Brown CC, et al. Effect of elevated hemoglobin A1c in diabetic patients on complication rates after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013;9:749–752.
130. Ballesta C, Berindoague R, Cabrera M, et al. Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2008;18:623–630.
131. Afraz S, Dang JT, Modasi A, et al. Bariatric surgery outcomes in oxygen-dependent patients: analysis of the MBSAQIP database. Surg Obes Relat Dis. 2019;15:1571–1580.
132. Rossetti G, Moccia F, Marra T, et al. Does Helicobacter pylori
infection have influence on outcome of laparoscopic sleeve gastrectomy for morbid obesity. Int J Surg. 2014;12(suppl 1):68–71.
133. Albawardi A, Almarzooqi S, Torab FC. Helicobacter pylori
in sleeve gastrectomies: prevalence and rate of complications. Int J Clin Exp Med. 2013;6:140–143.
134. Demirbas BT, Erdim A, Celikel C, et al. Is it necessary to send the sleeve gastrectomy specimens to pathology. Surg Laparosc Endosc Percutan Tech. 2019;29:117–119.
135. Almazeedi S, Al-sabah S, Al-mulla A, et al. Gastric histopathologies in patients undergoing laparoscopic sleeve gastrectomies. Obes Surg. 2013;23:314–319.
136. Mocanu V, Dang JT, Switzer N, et al. The effect of Helicobacter pylori
on postoperative outcomes in patients undergoing bariatric surgery: a systematic review and meta-analysis. Obes Surg. 2018;28:567–573.
137. Victorzon M, Victorzon S, Peromaa-haavisto P. Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature. Obes Surg. 2013;23:1692–1697.
138. Pilone V, Tramontano S, Renzulli M, et al. Omentopexy with Glubran®2 for reducing complications after laparoscopic sleeve gastrectomy: results of a randomized controlled study. BMC Surg. 2019;19(suppl 1):56.
139. Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010;20:462–467.
140. Kasalicky M, Michalsky D, Housova J, et al. Laparoscopic sleeve gastrectomy without an over-sewing of the staple line. Obes Surg. 2008;18:1257–1262.
141. Wang Y, Yi XY, Gong LL, et al. The effectiveness and safety of laparoscopic sleeve gastrectomy with different sizes of bougie calibration: a systematic review and meta-analysis. Int J Surg. 2018;49:32–38.
142. Sakran N, Raziel A, Gralnek IM, et al. Low incidence of postoperative leaks when using small-diameter calibrated bougies during laparoscopic sleeve gastrectomy: a retrospective cohort study. World J Surg. 2020;44:849–854.
143. 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.
144. Braga M, Ljungqvist O, Soeters P, et al. ESPEN Guidelines on Parenteral Nutrition: surgery. Clin Nutr. 2009;28:378–386.
145. Aggarwal S, Bhattacharjee H, Chander Misra M. Practice of routine intraoperative leak test during laparoscopic sleeve gastrectomy should not be discarded. Surg Obes Relat Dis. 2011;7:e24–e25.
146. Alasfar F, Chand B. Intraoperative endoscopy for laparoscopic Roux-en-Y gastric bypass: leak test and beyond. Surg Laparosc Endosc Percutan Tech. 2010;20:424–427.
147. Shin RB. Intraoperative endoscopic test resulting in no postoperative leaks from the gastric pouch and gastrojejunal anastomosis in 366 laparoscopic Roux-en-Y gastric bypasses. Obes Surg. 2004;14:1067–1069.
148. Dang JT, Szeto VG, Elnahas A, et al. Canadian consensus statement: enhanced recovery after surgery in bariatric surgery. Surg Endosc. 2020;34:1366–1375.
149. Adil MT, Aminian A, Bhasker AG, et al. Perioperative practices concerning sleeve gastrectomy—a survey of 863 surgeons with a cumulative experience of 520,230 procedures. Obes Surg. 2020;30:483–492.
150. Yolsuriyanwong K, Ingviya T, Kongkamol C, et al. Effects of intraoperative leak testing on postoperative leak-related outcomes after primary bariatric surgery: an analysis of the MBSAQIP database. Surg Obes Relat Dis. 2019;15:1530–1540.
151. Kirby GC, Macano CAW, Nyasavajjala SM, et al. The Birmingham experience of high-pressure methylene blue dye test during primary and revisional bariatric surgery: a retrospective cohort study. Ann Med Surg (Lond). 2017;23:32–34.
152. Howie E, Pournaras DJ, Mahon D. Staple line integrity test in sleeve gastrectomy. Ann R Coll Surg Engl. 2017;99:658.
153. Rogula T, Leifer D, Petrosky JA, et al. Stapler-less robotic partial gastrectomy: a safety and feasibility experimental study. Obes Surg. 2019;29:721–728.
154. De aretxabala X, Leon J, Wiedmaier G, et al. Gastric leak after sleeve gastrectomy: analysis of its management. Obes Surg. 2011;21:1232–1237.
155. Albanopoulos K, Alevizos L, Linardoutsos D, et al. Routine abdominal drains after laparoscopic sleeve gastrectomy: a retrospective review of 353 patients. Obes Surg. 2011;21:687–691.
156. Wahby M, Salama AF, Elezaby AF, et al. Is routine postoperative gastrografin study needed after laparoscopic sleeve gastrectomy? Experience of 712 cases. Obes Surg. 2013;23:1711–1717.
157. Welsch T, Von frankenberg M, Schmidt J, et al. Diagnosis and definition of anastomotic leakage from the surgeon’s perspective. Chirurg. 2011;82:48–55.
158. Bekheit M, Katri KM, Nabil W, et al. Earliest signs and management of leakage after bariatric surgeries: single institute experience. Alexandria J Med. 2013;49:29–33.
159. Bone RC, Balk RA, Cerra FB, et al. American Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101:1644–1655.
160. Arteaga-gonzález I, Martín-malagón A, Martín-pérez J, et al. Usefulness of clinical signs and diagnostic tests for suspected leaks in bariatric surgery. Obes Surg. 2015;25:1680–1684.
161. Dakwar A, Assalia A, Khamaysi I, et al. Late complication of laparoscopic sleeve gastrectomy. Case Rep Gastrointest Med. 2013;2013:136153.
162. Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204:47–55.
163. Hamilton EC, Sims TL, Hamilton TT, et al. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2003;17:679–684.
164. Stamou KM, Menenakos E, Dardamanis D, et al. Prospective comparative study of the efficacy of staple-line reinforcement in laparoscopic sleeve gastrectomy. Surg Endosc. 2011;25:3526–3530.
165. Jurowich C, Thalheimer A, Seyfried F, et al. Gastric leakage after sleeve gastrectomy-clinical presentation and therapeutic options. Langenbecks Arch Surg. 2011;396:981–987.
166. Dib F, Parenti LR, Boutten A, et al. Diagnostic performance of C-reactive protein in detecting post-operative infectious complications after laparoscopic sleeve gastrectomy. Obes Surg. 2017;27:3124–3132.
167. Bona D, Micheletto G, Bonitta G, et al. Does C-reactive protein have a predictive role in the early diagnosis of postoperative complications after bariatric surgery? Systematic review and bayesian meta-analysis. Obes Surg. 2019;29:3448–3456.
168. Hoehn RS, Seitz AP, Singer KE, et al. Enhanced recovery protocol for laparoscopic sleeve gastrectomy: are narcotics necessary. J Gastrointest Surg. 2019;23:1541–1546.
169. Bingham J, Shawhan R, Parker R, et al. Computed tomography scan versus upper gastrointestinal fluoroscopy for diagnosis of staple line leak following bariatric surgery. Am J Surg. 2015;209:810–814.
170. Mbadiwe T, Prevatt E, Duerinckx A, et al. Assessing the value of routine upper gastrointestinal contrast studies following bariatric surgery: a systematic review and meta-analysis. Am J Surg. 2015;209:616–622.
171. Tan JT, Kariyawasam S, Wijeratne T, et al. Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg. 2010;20:403–409.
172. Paspatis GA, Dumonceau JM, Barthet M, et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy. 2014;46:693–711.
173. Delko T, Mattiello D, Koestler T, et al. Computed tomography as primary postoperative follow-up after laparoscopic Roux-en-Y gastric bypass. World J Radiol. 2018;10:1–6.
174. Musella M, Cantoni V, Green R, et al. Efficacy of postoperative upper gastrointestinal series (UGI) and computed tomography (CT) scan in bariatric surgery: a meta-analysis on 7516 patients. Obes Surg. 2018;28:2396–2405.
175. Terterov D, Leung PH, Twells LK, et al. The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks. Can J Surg. 2017;60:335–341.
176. Lee SD, Khouzam MN, Kellum JM, et al. Selective, versus routine, upper gastrointestinal series leads to equal morbidity and reduced hospital stay in laparoscopic gastric bypass patients. Surg Obes Relat Dis. 2007;3:413–416.
177. Rahman U, Docimo S, Pryor AD, et al. Routine contrast imaging after bariatric surgery and the effect on hospital length of stay. Surg Obes Relat Dis. 2018;14:517–520.
178. Bruce J, Krukowski ZH, Al-khairy G, et al. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg. 2001;88:1157–1168.
179. Shah SGS. A Commentary on “Ensuring safe surgical care across resource settings via surgical outcomes data & quality improvement initiatives” (Int J Surg
2019 Aug 5. https://doi.org/ 10.1016/j.ijsu.2019.07.036). Int J Surg. 2019;72:14–15.
180. Bardini R, Asolati M, Ruol A, et al. Anastomosis. World J Surg. 1994;18:373–378.
181. Praveenraj P, Gomes RM, Kumar S, et al. Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: a tertiary care experience and design of a management algorithm. J Minim Access Surg. 2016;12:342–349.
182. Csendes A, Diaz JC, Burdiles P, et al. Classification and treatment of anastomotic leakage after extended total gastrectomy in gastric carcinoma. Hepatogastroenterology. 1990;37(suppl 2):174–177.
183. Isozaki H, Okajima K. How to reduce surgical complications after extended gastric surgery. Dig Surg. 1994;11:78–85.
184. Nambirajan L, Rintala RJ, Losty PD, et al. The value of early postoperative oesophagography following repair of oesophageal atresia. Pediatr Surg Int. 1998;13:76–78.
185. Al hajj G, Chemaly R. Fistula following laparoscopic sleeve gastrectomy: a proposed classification and algorithm for optimal management. Obes Surg. 2018;28:656–664.
186. Auldist AW, Beasley SW Beasley SW, Myers NA, Auldist AW. Esophageal complications. Oesophageal Atresia, 1st ed. London: Chapman & Hall; 1991:305–322.
187. Kumbhari V, Abu dayyeh BK. Keeping the fistula open: paradigm shift in the management of leaks after bariatric surgery. Endoscopy. 2016;48:789–791.
188. Smith ZL, Park KH, Llano EM, et al. Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort. Surg Obes Relat Dis. 2019;15:850–855.
189. De moura DTH, De moura EGH, Neto MG, et al. Outcomes of a novel bariatric stent in the management of sleeve gastrectomy leaks: a multicenter study. Surg Obes Relat Dis. 2019;15:1241–1251.
190. Donatelli G, Catheline JM, Dumont JL, et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. Obes Surg. 2015;25:1258–1260.
191. Rodrigues-pinto E, Repici A, Donatelli G, et al. International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks. Endosc Int Open. 2019;7:E1671–E1682.
192. Bashah M, Khidir N, El-matbouly M. Management of leak after sleeve gastrectomy: outcomes of 73 cases, treatment algorithm and predictors of resolution. Obes Surg. 2020;30:515–520.
193. Lorenzo D, Guilbaud T, Gonzalez JM, et al. Endoscopic treatment of fistulas after sleeve gastrectomy: a comparison of internal drainage versus closure. Gastrointest Endosc. 2018;87:429–437.
194. 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.
195. Dammaro C, Lainas P, Dumont JL, et al. Endoscopic internal drainage coupled to prompt external drainage mobilization is an effective approach for the treatment of complicated cases of sleeve gastrectomy. Obes Surg. 2019;29:2929–2935.
196. Nedelcu M, Manos T, Cotirlet A, et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm adressing leak size and gastric stenosis. Obes Surg. 2015;25:559–563.
197. 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.
198. Al-kurd A, Grinbaum R, Abubeih A, et al. Not all leaks are created equal: a comparison between leaks after sleeve gastrectomy and Roux-En-Y gastric bypass. Obes Surg. 2018;28:3775–3782.
199. Serrot FJ, Lin E. Comment on: outcomes of endoscopic treatment of leaks and fistulae following sleeve gastrectomy: results from a large multicenter U.S. cohort. Surg Obes Relat Dis. 2019;15:e25–e27.
200. Diaz R, Welsh LK, Perez JE, et al. Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy: meeting presentations: Digestive Disease Week 2019. Endosc Int Open. 2020;8:E70–E75.
201. Foo JW, Balshaw J, Tan MHL, et al. Leaks in fixed-ring banded sleeve gastrectomies: a management approach. Surg Obes Relat Dis. 2017;13:1259–1264.
202. Copaescu C, Smeu B, Habibi M. Roux-en-Y feeding jejunostomy—the preferred surgical option for enteral nutrition in patients with leaks or fistula after gastric sleeve. Chirurgia (Bucur). 2019;114:798–808.
203. Joo MK. Endoscopic approach for major complications of bariatric surgery. Clin Endosc. 2017;50:31–41.
204. Althuwaini S, Bamehriz F, Alobaid O, et al. Identification of bacterial and fungal pathogens in patients with post-laparoscopic sleeve gastrectomy leakage. Obes Surg. 2018;28:3965–3968.
205. Willingham FF, Buscaglia JM. Endoscopic management of gastrointestinal leaks and fistulae. Clin Gastroenterol Hepatol. 2015;13:1714–1721.
206. Schmidt F, Mennigen R, Vowinkel T, et al. Endoscopic vacuum therapy (EVT)—a new concept for complication management in bariatric surgery. Obes Surg. 2017;27:2499–2505.
207. Loo GH, Rajan R, Nik mahmood NRK. Staple-line leak post primary sleeve gastrectomy. A two patient case series and literature review. Ann Med Surg (Lond). 2019;44:72–76.
208. 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.
209. Madan AK, Lanier B, Tichansky DS. Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass. Am Surg. 2006;72:586–590.
210. Durak E, Inabnet WB, Schrope B, et al. Incidence and management of enteric leaks after gastric bypass for morbid obesity during a 10-year period. Surg Obes Relat Dis. 2008;4:389–393.
211. Chouillard E, Chahine E, Schoucair N, et al. Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post-sleeve gastrectomy fistula. Surg Endosc. 2014;28:1954–1960.
212. Contival N, Menahem B, Gautier T, et al. Guiding the non-bariatric surgeon through complications of bariatric surgery. J Visc Surg. 2018;155:27–40.
213. Oshiro T, Kasama K, Umezawa A, et al. Successful management of refractory staple line leakage at the esophagogastric junction after a sleeve gastrectomy using the HANAROSTENT. Obes Surg. 2010;20:530–534.
214. Pequignot A, Fuks D, Verhaeghe P, et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy. Obes Surg. 2012;22:712–720.
215. Hughes D, Hughes I, Khanna A. Management of staple line leaks following sleeve gastrectomy—a systematic review. Obes Surg. 2019;29:2759–2772.
216. Amor IB, Debs T, Dalmonte G, et al. Laparoscopic Roux-En-Y Fistulo-Jejunostomy, a preferred technique after failure of endoscopic and radiologic management of fistula post sleeve gastrectomy. Obes Surg. 2019;29:749–750.
217. Lainas P, Schoucair N, Dammaro C, et al. Salvage procedures for chronic gastric leaks after sleeve gastrectomy: the role of laparoscopic Roux-en-Y fistulo-jejunostomy. Ann Transl Med. 2019;7(suppl 3):S119.
218. Boumitri C, Kumta NA, Patel M, et al. Closing perforations and postperforation management in endoscopy: duodenal, biliary, and colorectal. Gastrointest Endosc Clin N Am. 2015;25:47–54.
219. Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007. Obes Surg. 2008;18:487–496.
220. Baltasar A, Serra C, Bengochea M, et al. Use of Roux limb as remedial surgery for sleeve gastrectomy fistulas. Surg Obes Relat Dis. 2008;4:759–763.
221. Ben amor I, Debs T, Petrucciani N, et al. Chronic fistula post laparoscopic nissen sleeve gastrectomy: conversion to Roux-en-Y Gastric bypass. Obes Surg. 2019;29:3414–3415.
222. Barajas-gamboa JS, Landreneau J, Abril C, et al. Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for complications: outcomes from a tertiary referral center in the Middle East. Surg Obes Relat Dis. 2019;15:1690–1695.
223. Amor IB, Lainas P, Kassir R, et al. Laparoscopic Roux-en-Y double fistulo-jejunostomy for chronic gastric leaks after converted vertical banded gastroplasty to sleeve gastrectomy. Obes Surg. 2020;30:378–380.
224. Mcheimeche H, Dbouk SH, Saheli R, et al. Double baltazar procedure for repair of gastric leakage post-sleeve gastrectomy from two sites: case report of new surgical technique. Obes Surg. 2018;28:2092–2095.
225. Saglam K, Aktas A, Gundogan E, et al. Management of acute sleeve gastrectomy leaks by conversion to Roux-en-Y gastric bypass: a small case series. Obes Surg. 2017;27:3061–3063.
226. Takahashi H, Strong AT, Guerron AD, et al. An Odyssey of complications from band, to sleeve, to bypass; definitive laparoscopic completion gastrectomy with distal esophagectomy and esophagojejunostomy for persistent leak. Surg Endosc. 2018;32:507–510.
227. Verlaan T, Voermans RP, Van berge henegouwen MI, et al. Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature. Gastrointest Endosc. 2015;82:618.e5–628.e5.
228. Stavropoulos SN, Modayil R, Friedel D. Closing perforations and postperforation management in endoscopy: esophagus and stomach. Gastrointest Endosc Clin N Am. 2015;25:29–45.
229. 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.
230. Donatelli G, Fuks D, Tabchouri N, et al. Seal or drain? Endoscopic management of leaks following sleeve gastrectomy. Surg Innov. 2018;25:5–6.
231. Benosman H, Rahmi G, Perrod G, et al. Endoscopic management of post-bariatric surgery fistula: a Tertiary Care Center Experience. Obes Surg. 2018;28:3910–3915.
232. Bège T, Emungania O, Vitton V, et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc. 2011;73:238–244.
233. Baptista A, Hourneaux de moura DT, Jirapinyo P, et al. Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas. Gastrointest Endosc. 2019;89:671–679.e1.
234. Huang PY, Tsai KL, Liang CM, et al. Prognostic factors of patients with gastroenteropancreatic neuroendocrine neoplasms. Kaohsiung J Med Sci. 2018;34:650–656.
235. Lemmers A, Tan DM, Ibrahim M, et al. Transluminal or percutaneous endoscopic drainage and debridement of abscesses after bariatric surgery: a case series. Obes Surg. 2015;25:2190–2199.
236. Lang H, Piso P, Stukenborg C, et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol. 2000;26:168–171.
237. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–271.
238. Rodella L, Laterza E, De manzoni G, et al. Endoscopic clipping of anastomotic leakages in esophagogastric surgery. Endoscopy. 1998;30:453–456.
239. Vedantam S, Roberts J. Endoscopic stents in the management of bariatric complications: our algorithm and outcomes. Obes Surg. 2020;30:1150–1158.
240. Ritter LA, Wang AY, Sauer BG, et al. Healing of complicated gastric leaks in bariatric patients using endoscopic clips. JSLS. 2013;17:481–483.
241. Yilmaz B, Unlu O, Roach EC, et al. Endoscopic clips for the closure of acute iatrogenic perforations: where do we stand? Dig Endosc. 2015;27:641–648.
242. Raju GS. Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks. Dig Endosc. 2014;26(suppl 1):95–104.
243. Rogalski P, Swidnicka-Siergiejko A, Wasielica-Berger J, et al. Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis. Surg Endosc. 2020. doi: 10.1007/s00464-020-07471-1.
244. Merrifield BF, Lautz D, Thompson CC. Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach. Gastrointest Endosc. 2006;63:710–714.
245. Moon RC, Shah N, Teixeira AF, et al. Management of staple line leaks following sleeve gastrectomy. Surg Obes Relat Dis. 2015;11:54–59.
246. Kirschniak A, Kratt T, Stüker D, et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc. 2007;66:162–167.
247. Haito-chavez Y, Law JK, Kratt T, et al. International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video). Gastrointest Endosc. 2014;80:610–622.
248. Rustagi T, Mccarty TR, Aslanian HR. Endoscopic treatment of gastrointestinal perforations, leaks, and fistulae. J Clin Gastroenterol. 2015;49:804–809.
249. Keren D, Eyal O, Sroka G, et al. Over-the-scope clip (OTSC) system for sleeve gastrectomy leaks. Obes Surg. 2015;25:1358–1363.
250. Surace M, Mercky P, Demarquay JF, et al. Endoscopic management of GI fistulae with the over-the-scope clip system (with video). Gastrointest Endosc. 2011;74:1416–1419.
251. Mercky P, Gonzalez JM, Aimore bonin E, et al. Usefulness of over-the-scope clipping system for closing digestive fistulas. Dig Endosc. 2015;27:18–24.
252. Kim JH, Park JJ, Jung IW, et al. Treatment of traumatic esophagopleural fistula using the over-the-scope-clip system. Clin Endosc. 2015;48:440–443.
253. Anastasiou J, Hussameddin A, Al quorain A. Mind the gap: successful endoscopic closure of a large gastric sleeve leak using an endoscopic stent and over-the-scope clips. Case Rep Gastroenterol. 2017;11:763–768.
254. Iacopini F, Di lorenzo N, Altorio F, et al. Over-the-scope clip closure of two chronic fistulas after gastric band penetration. World J Gastroenterol. 2010;16:1665–1669.
255. Boru CE, Angelis F, Iossa A, et al. Persistent fistula after sleeve gastrectomy: a chronic dilemma. Chirurgia (Bucur). 2019;114:790–797.
256. Law R, Wong kee song LM, Irani S, et al. Immediate technical and delayed clinical outcome of fistula closure using an over-the-scope clip device. Surg Endosc. 2015;29:1781–1786.
257. Shoar S, Poliakin L, Khorgami Z, et al. Efficacy and safety of the over-the-scope clip (OTSC) system in the management of leak and fistula after laparoscopic sleeve gastrectomy: a systematic review. Obes Surg. 2017;27:2410–2418.
258. Bona D, Giovannelli A, Micheletto G, et al. Treatment of persistent leaks after laparoscopic sleeve gastrectomy with the simultaneous over-the-scope clip (OTSC) and mega stent strategy. Obes Surg. 2020;30:3615–3619.
259. Farnik H, Driller M, Kratt T, et al. Indication for “Over the scope” (OTS)-clip vs. covered self-expanding metal stent (cSEMS) is unequal in upper gastrointestinal leakage: results from a retrospective head-to-head comparison. PLoS ONE. 2015;10:e0117483.
260. Bhat YM, Banerjee S, Barth BA, et al. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc. 2013;78:209–215.
261. Kowalski C, Kastuar S, Mehta V, et al. Endoscopic injection of fibrin sealant in repair of gastrojejunostomy leak after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007;3:438–442.
262. Papavramidis ST, Eleftheriadis EE, Papavramidis TS, et al. Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant. Gastrointest Endosc. 2004;59:296–300.
263. Brolin RE, Lin JM. Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift. Surg Obes Relat Dis. 2013;9:229–233.
264. Papavramidis ST, Eleftheriadis EE, Apostolidis DN, et al. Endoscopic fibrin sealing of high-output non-healing gastrocutaneous fistulas after vertical gastroplasty in morbidly obese patients. Obes Surg. 2001;11:766–769.
265. Lippert E, Klebl FH, Schweller F, et al. Fibrin glue in the endoscopic treatment of fistulae and anastomotic leakages of the gastrointestinal tract. Int J Colorectal Dis. 2011;26:303–311.
266. Voermans RP, Le moine O, Von renteln D, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10:603–608.
267. Lee YC, Na HG, Suh JH, et al. Three cases of fistulae arising from gastrointestinal tract treated with endoscopic injection of Histoacryl. Endoscopy. 2001;33:184–186.
268. Papavramidis TS, Kotzampassi K, Kotidis E, et al. Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch. J Gastroenterol Hepatol. 2008;23:1802–1805.
269. Cho J, Sahakian AB. Endoscopic closure of gastrointestinal fistulae and leaks. Gastrointest Endosc Clin N Am. 2018;28:233–249.
270. Vilallonga R, Himpens J, Bosch B, et al. Role of percutaneous glue treatment after persisting leak after laparoscopic sleeve gastrectomy. Obes Surg. 2016;26:1378–1383.
271. Maluf-filho F, Hondo F, Halwan B, et al. Endoscopic treatment of Roux-en-Y gastric bypass-related gastrocutaneous fistulas using a novel biomaterial. Surg Endosc. 2009;23:1541–1545.
272. Toussaint E, Eisendrath P, Kwan V, et al. Endoscopic treatment of postoperative enterocutaneous fistulas after bariatric surgery with the use of a fistula plug: report of five cases. Endoscopy. 2009;41:560–563.
273. Champagne BJ, O’connor LM, Ferguson M, et al. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum. 2006;49:1817–1821.
274. Johnson EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum. 2006;49:371–376.
275. Sousa DON, Dharia DOR, Mehta DOS, et al. Endoscopic use of EpiFix-dehydrated Human Amnion/Chorion Membrane (dHACM) allograft in patients with gastric leak following sleeve gastrectomy. J Surg Case Rep. 2017;2017:rjx184.
276. Sharaiha RZ, Kumta NA, Defilippis EM, et al. A large multicenter experience with endoscopic suturing
for management of gastrointestinal defects and stent anchorage in 122 patients: a retrospective review. J Clin Gastroenterol. 2016;50:388–392.
277. Mukewar S, Kumar N, Catalano M, et al. Safety and efficacy of fistula closure by endoscopic suturing
: a multi-center study. Endoscopy. 2016;48:1023–1028.
278. Kantsevoy SV, Bitner M, Davis JM, et al. Endoscopic suturing
closure of large iatrogenic colonic perforation. Gastrointest Endosc. 2015;82:754–755.
279. Overcash WT. Natural orifice surgery (NOS) using StomaphyX for repair of gastric leaks after bariatric revisions. Obes Surg. 2008;18:882–885.
280. Cai JX, Khashab MA, Okolo PI, et al. Full-thickness endoscopic suturing
of staple-line leaks following laparoscopic sleeve gastrectomy. Endoscopy. 2014;46(suppl 1 UCTN):E623–E624.
281. Chon SH, Toex U, Plum PS, et al. Efficacy and feasibility of OverStitch suturing of leaks in the upper gastrointestinal tract. Surg Endosc. 2019;34:3861–3869.
282. Fernandez-esparrach G, Lautz DB, Thompson CC. Endoscopic repair of gastrogastric fistula after Roux-en-Y gastric bypass: a less-invasive approach. Surg Obes Relat Dis. 2010;6:282–288.
283. Lamb LC, Lawlor MK, Tishler DS, et al. Use of an endoscopic suturing
platform for the management of staple line dehiscence after laparoscopic sleeve gastrectomy. Obes Surg. 2020;30:895–900.
284. Bhayani NH, Swanström LL. Endoscopic therapies for leaks and fistulas after bariatric surgery. Surg Innov. 2014;21:90–97.
285. Gagner M, Deitel M, Erickson AL, et al. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013;23:2013–2017.
286. Emre A, Sertkaya M, Akbulut S, et al. Self-expandable metallic stent application for the management of upper gastrointestinal tract disease. Turk J Surg. 2018;34:101–105.
287. Persson S, Rouvelas I, Kumagai K, et al. Treatment of esophageal anastomotic leakage with self-expanding metal stents: analysis of risk factors for treatment failure. Endosc Int Open. 2016;4:E420–E426.
288. Dasari BV, Neely D, Kennedy A, et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg. 2014;259:852–860.
289. Spaander MC, Baron TH, Siersema PD, et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48:939–948.
290. Jain D, Patel U, Ali S, et al. Efficacy and safety of lumen-apposing metal stent for benign gastrointestinal stricture. Ann Gastroenterol. 2018;31:425–438.
291. Donatelli G, Ferretti S, Vergeau BM, et al. Endoscopic Internal Drainage with Enteral Nutrition (EDEN) for treatment of leaks following sleeve gastrectomy. Obes Surg. 2014;24:1400–1407.
292. Donatelli G, Dhumane P, Perretta S, et al. Endoscopic placement of fully covered self expanding metal stents for management of post-operative foregut leaks. J Minim Access Surg. 2012;8:118–124.
293. Hill C, Khalil BK, Barola S, et al. Inversion technique for the removal of partially covered self-expandable metallic stents. Obes Surg. 2018;28:161–168.
294. Eisendrath P, Deviere J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol. 2015;12:701–710.
295. Simon F, Siciliano I, Gillet A, et al. Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time. Obes Surg. 2013;23:687–692.
296. Salinas A, Baptista A, Santiago E, et al. Self-expandable metal stents to treat gastric leaks. Surg Obes Relat Dis. 2006;2:570–572.
297. Eisendrath P, Cremer M, Himpens J, et al. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy. 2007;39:625–630.
298. El mourad H, Himpens J, Verhofstadt J. Stent treatment for fistula after obesity surgery: results in 47 consecutive patients. Surg Endosc. 2013;27:808–816.
299. Alazmi W, Al-sabah S, Ali DA, et al. Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature. Surg Endosc. 2014;28:3425–3428.
300. Murino A, Arvanitakis M, Le moine O, et al. Effectiveness of endoscopic management using self-expandable metal stents in a large cohort of patients with post-bariatric leaks. Obes Surg. 2015;25:1569–1576.
301. Fishman S, Shnell M, Gluck N, et al. Use of sleeve-customized self-expandable metal stents for the treatment of staple-line leakage after laparoscopic sleeve gastrectomy. Gastrointest Endosc. 2015;81:1291–1294.
302. Freedman J, Jonas E, Näslund E, et al. Treatment of leaking gastrojejunostomy after gastric bypass surgery with special emphasis on stenting. Surg Obes Relat Dis. 2013;9:554–558.
303. Martin del campo SE, Mikami DJ, Needleman BJ, et al. Endoscopic stent placement for treatment of sleeve gastrectomy leak: a single institution experience with fully covered stents. Surg Obes Relat Dis. 2018;14:453–461.
304. Wong RF, Adler DG, Hilden K, et al. Retrievable esophageal stents for benign indications. Dig Dis Sci. 2008;53:322–329.
305. Almadi MA, Bamihriz F, Alharbi O, et al. Use of self-expandable metal stents in the treatment of leaks complicating laparoscopic sleeve gastrectomy: a cohort study. Obes Surg. 2018;28:1562–1570.
306. Aydin MT, Alahdab YÖ, Aras O, et al. Endoscopic stenting for laparoscopic sleeve gastrectomy leaks. Ulus Cerrahi Derg. 2016;32:275–280.
307. Okazaki O, Bernardo WM, Brunaldi VO, et al. Efficacy and safety of stents in the treatment of fistula after bariatric surgery: a systematic review and meta-analysis. Obes Surg. 2018;28:1788–1796.
308. Donatelli G, Guerriero L, Cereatti F, et al. Endoscopic fistula-jejunostomy for chronic gastro-jejunal fistula after sleeve gastrectomy. Obes Surg. 2018;28:1456–1457.
309. Takimoto Y, Nakamura T, Yamamoto Y, et al. The experimental replacement of a cervical esophageal segment with an artificial prosthesis with the use of collagen matrix and a silicone stent. J Thorac Cardiovasc Surg. 1998;116:98–106.
310. Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008;206:935–938.
311. Blackmon SH, Santora R, Schwarz P, et al. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg. 2010;89:931–936.
312. Leenders BJ, Stronkhorst A, Smulders FJ, et al. Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital. Surg Endosc. 2013;27:2751–2759.
313. Orive-calzada A, Calderón-garcía Á, Bernal-martínez A, et al. Closure of benign leaks, perforations, and fistulas with temporary placement of fully covered metal stents: a retrospective analysis. Surg Laparosc Endosc Percutan Tech. 2014;24:528–536.
314. Quezada N, Maiz C, Daroch D, et al. Effect of early use of covered self-expandable endoscopic stent on the treatment of postoperative stapler line leaks. Obes Surg. 2015;25:1816–1821.
315. Hindy P, Hong J, Lam-tsai Y, et al. A comprehensive review of esophageal stents. Gastroenterol Hepatol (N Y). 2012;8:526–534.
316. Ackroyd R, Watson DI, Devitt PG, et al. Expandable metallic stents should not be used in the treatment of benign esophageal strictures. J Gastroenterol Hepatol. 2001;16:484–487.
317. Hramiec JE, O’shea MA, Quinlan RM. Expandable metallic esophageal stents in benign disease: a cause for concern. Surg Laparosc Endosc. 1998;8:40–43.
318. Guzaiz N, Arabi M, Khankan A, et al. Gastroesophageal stenting for the management of post sleeve gastrectomy leak. A single institution experience. Saudi Med J. 2016;37:1339–1343.
319. Tsai YN, Wang HP, Huang CK, et al. Endoluminal stenting for the management of leak following sleeve gastrectomy and loop duodenojejunal bypass with sleeve gastrectomy. Kaohsiung J Med Sci. 2018;34:43–48.
320. Van halsema EE, Wong kee song LM, Baron TH, et al. Safety of endoscopic removal of self-expandable stents after treatment of benign esophageal diseases. Gastrointest Endosc. 2013;77:18–28.
321. Thomas S, Siddiqui AA, Taylor LJ, et al. Fully-covered esophageal stent migration rates in benign and malignant disease: a multicenter retrospective study. Endosc Int Open. 2019;7:E751–E756.
322. Ngamruengphong S, Sharaiha RZ, Sethi A, et al. Endoscopic suturing
for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study. Endoscopy. 2016;48:802–808.
323. Irani S, Baron TH, Gluck M, et al. Preventing migration of fully covered esophageal stents with an over-the-scope clip device (with videos). Gastrointest Endosc. 2014;79:844–851.
324. Ngamruengphong S, Sharaiha RZ, Sethi A, et al. Endoscopic suturing
for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study. Endoscopy. 2016;48:808.
325. Vanbiervliet G, Filippi J, Karimdjee BS, et al. The role of clips in preventing migration of fully covered metallic esophageal stents: a pilot comparative study. Surg Endosc. 2012;26:53–59.
326. Spaander MC. Do we need to fixate a fully covered esophageal metal stent. Endoscopy. 2016;48:787–788.
327. Rieder E, Dunst CM, Martinec DV, et al. Endoscopic suture fixation of gastrointestinal stents: proof of biomechanical principles and early clinical experience. Endoscopy. 2012;44:1121–1126.
328. Fujii LL, Bonin EA, Baron TH, et al. Utility of an endoscopic suturing
system for prevention of covered luminal stent migration in the upper GI tract. Gastrointest Endosc. 2013;78:787–793.
329. Wilcox VT, Huang AY, Tariq N, et al. Endoscopic suture fixation of self-expanding metallic stents with and without submucosal injection. Surg Endosc. 2015;29:24–29.
330. Kumbhari V, Tieu AH, Cai JX, et al. Novel technique for the management of staple line leaks after sleeve gastrectomy. Gastrointest Endosc. 2015;82:748.
331. Hirdes MM, Vleggaar FP, Van der linde K, et al. Esophageal perforation due to removal of partially covered self-expanding metal stents placed for a benign perforation or leak. Endoscopy. 2011;43:156–159.
332. Van heel NC, Haringsma J, Spaander MC, et al. Short-term esophageal stenting in the management of benign perforations. Am J Gastroenterol. 2010;105:1515–1520.
333. Seven G, Irani S, Ross AS, et al. Partially versus fully covered self-expanding metal stents for benign and malignant esophageal conditions: a single center experience. Surg Endosc. 2013;27:2185–2192.
334. Hirdes MM, Siersema PD, Houben MH, et al. Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents. Am J Gastroenterol. 2011;106:286–293.
335. Van boeckel PG, Dua KS, Weusten BL, et al. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol. 2012;12:19.
336. Van wezenbeek MR, De milliano MM, Nienhuijs SW, et al. A specifically designed stent for anastomotic leaks after bariatric surgery: experiences in a tertiary referral hospital. Obes Surg. 2016;26:1875–1880.
337. Klimczak T, Klimczak J, Szewczyk T, et al. Endoscopic treatment of leaks after laparoscopic sleeve gastrectomy using MEGA esophageal covered stents. Surg Endosc. 2018;32:2038–2045.
338. Galloro G, Magno L, Musella M, et al. A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series. Surg Obes Relat Dis. 2014;10:607–611.
339. Fischer A, Bausch D, Richter-schrag HJ. Use of a specially designed partially covered self-expandable metal stent (PSEMS) with a 40-mm diameter for the treatment of upper gastrointestinal suture or staple line leaks in 11 cases. Surg Endosc. 2013;27:642–647.
340. Garofalo F, Noreau-nguyen M, Denis R, et al. Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents. Surg Obes Relat Dis. 2017;13:925–932.
341. Currò G, Komaei I, Lazzara C, et al. Management of staple line leaks following laparoscopic sleeve gastrectomy for morbid obesity. Surg Technol Int. 2018;33:111–118.
342. Shehab H, Mikhail H. Gastroseal: a novel stent design for the management of post-bariatric surgery leaks. ACG Case Rep J. 2018;5:e85.
343. Boerlage TCC, Houben GPM, Groenen MJM, et al. A novel fully covered double-bump stent for staple line leaks after bariatric surgery: a retrospective analysis. Surg Endosc. 2018;32:3174–3180.
344. Galloro G, Ruggiero S, Russo T, et al. Staple-line leak after sleve gastrectomy in obese patients: a hot topic in bariatric surgery. World J Gastrointest Endosc. 2015;7:843–846.
345. Aburajab MA, Max JB, Ona MA, et al. Covered esophageal stenting is effective for symptomatic gastric lumen narrowing and related complications following laparoscopic sleeve gastrectomy. Dig Dis Sci. 2017;62:3077–3083.
346. Madruga neto AC, Brunaldi VO, Okazaki O, et al. Stent migration requiring surgical removal: a serious adverse event after bariatric megastent placement. Endoscopy. 2018;50:E344–E345.
347. Lorenzo-zúñiga V, Moreno-de-vega V, Marín I, et al. Biodegradable stents in gastrointestinal endoscopy. World J Gastroenterol. 2014;20:2212–2217.
348. Aras A, Oran E, Bozkurt MA, et al. Successful treatment of post-sleeve gastric leak with an uncovered biodegradable stent. Acta Endosc. 2014;44:382–384.
349. Shehab H, Abdallah E, Gawdat K, et al. Large bariatric-specific stents and over-the-scope clips in the management of post-bariatric surgery leaks. Obes Surg. 2018;28:15–24.
350. Bouchard S, Eisendrath P, Toussaint E, et al. Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract. Endoscopy. 2016;48:809–816.
351. Thompson CC, Kumar N, Slattery J, et al. A standardized method for endoscopic necrosectomy improves complication and mortality rates. Pancreatology. 2016;16:66–72.
352. Puig CA, Waked TM, Baron TH, et al. The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery. Surg Obes Relat Dis. 2014;10:613–617.
353. 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.
354. Baretta G, Campos J, Correia S, et al. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc. 2015;29:1714–1720.
355. Shnell M, Gluck N, Abu-abeid S, et al. Use of endoscopic septotomy for the treatment of late staple-line leaks after laparoscopic sleeve gastrectomy. Endoscopy. 2017;49:59–63.
356. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc. 2005;62:92–100.
357. Boumitri C, Brown E, Kahaleh M. Necrotizing pancreatitis: current management and therapies. Clin Endosc. 2017;50:357–365.
358. Vila JJ, Carral D, Fernández-urien I. Pancreatic pseudocyst drainage guided by endoscopic ultrasound. World J Gastrointest Endosc. 2010;2:193–197.
359. Itoi T, Itokawa F, Tsuchiya T, et al. EUS-guided pancreatic pseudocyst drainage: simultaneous placement of stents and nasocystic catheter using double-guidewire technique. Dig Endosc. 2009;21(suppl 1):S53–S56.
360. Brangewitz M, Voigtländer T, Helfritz FA, et al. Endoscopic closure of esophageal intrathoracic leaks: stent versus endoscopic vacuum-assisted closure, a retrospective analysis. Endoscopy. 2013;45:433–438.
361. Donatelli G, Dumont JL, Cereatti F, et al. Endoscopic internal drainage as first-line treatment for fistula following gastrointestinal surgery: a case series. Endosc Int Open. 2016;4:E647–E651.
362. Gonzalez JM, Lorenzo D, Guilbaud T, et al. Internal endoscopic drainage as first line or second line treatment in case of postsleeve gastrectomy fistulas. Endosc Int Open. 2018;6:E745–E750.
363. Giuliani A, Romano L, Marchese M, et al. Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review. Surg Obes Relat Dis. 2019;15:1414–1419.
364. Rodrigues-pinto E, Morais R, Vilas-boas F, et al. Role of endoscopic vacuum therapy, internal drainage, and stents for postbariatric leaks. VideoGIE. 2019;4:481–485.
365. Ikejima K, Yaginuma R, Watanabe S. Anti-viral therapy of type C chronic hepatitis. 2. Progression of type C chronic hepatitis and resistance to treatment. 2) Participation of host factors. Nippon Naika Gakkai Zasshi. 2008;97:69–74.
366. Gupta T, Lemmers A, Tan D, et al. EUS-guided transmural drainage of postoperative collections. Gastrointest Endosc. 2012;76:1259–1265.
367. Machlab S, Pascua-Solé M, Hernández L, et al. Endoscopic Ultrasound (EUS)-guided drainage of a postsleeve gastrectomy subphrenic collection using a lumen apposition stent. Obes Surg. 2020;30:3236–3238.
368. Gagner M. Comment on: Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review. Surg Obes Relat Dis. 2019;15:1419.
369. Rebibo L, Delcenserie R, Brazier F, et al. Treatment of gastric leaks after sleeve gastrectomy. Endoscopy. 2016;48:590.
370. Marchese M, Romano L, Giuliani A, et al. A case of intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak. Int J Surg Case Rep. 2018;53:367–369.
371. Alatwan AA, Aljewaied A, Alkhadher T, et al. A complication of an endoscopic pigtail stent migration into the cavity during deployment as a treatment for gastric leak. Case Rep Surg. 2019;2019:6974527.
372. Ahrens M, Schulte T, Egberts J, et al. Drainage of esophageal leakage using endoscopic vacuum therapy: a prospective pilot study. Endoscopy. 2010;42:693–698.
373. Holle G, Riedel K, Von gregory H, et al. Vacuum-assisted closure therapy. Current status and basic research. Unfallchirurg. 2007;110:490–504.
374. Morell B, Murray F, Vetter D, et al. Endoscopic vacuum therapy (EVT) for early infradiaphragmal leakage after bariatric surgery-outcomes of six consecutive cases in a single institution. Langenbecks Arch Surg. 2019;404:115–121.
375. Leeds SG, Burdick JS. Management of gastric leaks after sleeve gastrectomy with endoluminal vacuum (E-Vac) therapy. Surg Obes Relat Dis. 2016;12:1278–1285.
376. Szymanski K, Ontiveros E, Burdick JS, et al. Endolumenal vacuum therapy and fistulojejunostomy in the management of sleeve gastrectomy staple line leaks. Case Rep Surg. 2018;2018:2494069.
377. Pines G, Bar I, Elami A, et al. Modified endoscopic vacuum therapy for nonhealing esophageal anastomotic leak: technique description and review of literature. J Laparoendosc Adv Surg Tech A. 2018;28:33–40.
378. Morykwas MJ, Simpson J, Punger K, et al. Vacuum-assisted closure: state of basic research and physiologic foundation. Plast Reconstr Surg. 2006;117(suppl):121S–126S.
379. Seyfried F, Reimer S, Miras AD, et al. Successful treatment of a gastric leak after bariatric surgery using endoluminal vacuum therapy. Endoscopy. 2013;45(suppl 2 UCTN):E267–E268.
380. Bludau M, Hölscher AH, Herbold T, et al. Management of upper intestinal leaks using an endoscopic vacuum-assisted closure system (E-VAC). Surg Endosc. 2014;28:896–901.
381. Kuehn F, Schiffmann L, Rau BM, et al. Surgical endoscopic vacuum therapy for anastomotic leakage and perforation of the upper gastrointestinal tract. J Gastrointest Surg. 2012;16:2145–2150.
382. Valli PV, Mertens JC, Kröger A, et al. Stent-over-sponge (SOS): a novel technique complementing endosponge therapy for foregut leaks and perforations. Endoscopy. 2018;50:148–153.
383. Archid R, Wichmann D, Klingert W, et al. Endoscopic vacuum therapy for staple line leaks after sleeve gastrectomy. Obes Surg. 2020;30:1310–1315.
384. Mencio MA, Ontiveros E, Burdick JS, et al. Use of a novel technique to manage gastrointestinal leaks with endoluminal negative pressure: a single institution experience. Surg Endosc. 2018;32:3349–3356.
385. Mennigen R, Harting C, Lindner K, et al. Comparison of endoscopic vacuum therapy versus stent for anastomotic leak after esophagectomy. J Gastrointest Surg. 2015;19:1229–1235.
386. Schniewind B, Schafmayer C, Voehrs G, et al. Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study. Surg Endosc. 2013;27:3883–3890.
387. Laukoetter MG, Mennigen R, Neumann PA, et al. Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study. Surg Endosc. 2017;31:2687–2696.
388. 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.
389. 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.
390. Ortega CB, Guerron AD, Portenier D. Endoscopic abscess septotomy: a less invasive approach for the treatment of sleeve gastrectomy leaks. J Laparoendosc Adv Surg Tech A. 2018;28:859–863.
391. Yu JX, Schulman AR. Management of a refractory leak after sleeve gastrectomy: the endoscopic armamentarium. VideoGIE. 2019;4:372–374.
392. Fazi J, Nasr J, Szoka N. Endoscopic septotomy and dilation of chronic sleeve gastrectomy leak. Surg Obes Relat Dis. 2019;15:2002.
393. Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;21:1520–1529.
394. Guerron AD, Ortega CB, Portenier D. Endoscopic abscess septotomy for management of sleeve gastrectomy leak. Obes Surg. 2017;27:2672–2674.
395. Rogalski P, Daniluk J, Baniukiewicz A, et al. Endoscopic management of gastrointestinal perforations, leaks and fistulas. World J Gastroenterol. 2015;21:10542–10552.
396. De moura DTH, Baptista A, Jirapinyo P, et al. Role of cardiac septal occluders in the treatment of gastrointestinal fistulas: a systematic review. Clin Endosc. 2020;53:37–48.
397. Young JA, Shimi SM, Alijani A, et al. Occlusion of a neo-esophageal-bronchial fistula using the Amplatzer Vascular Plug 2. Diagn Interv Radiol. 2013;19:259–262.
398. Koo JH, Park KB, Choo SW, et al. Embolization of postsurgical esophagopleural fistula with AMPLATZER vascular plug, coils, and Histoacryl glue. J Vasc Interv Radiol. 2010;21:1905–1910.
399. Kiliçkesmez Ö, Andiç C, Oğuzkurt L. Delayed failure of rectovaginal fistula embolization with Amplatzer vascular plug 2. Diagn Interv Radiol. 2014;20:511–512.
400. Sun M, Pan R, Kong X, et al. Successful closure of postoperative esophagobronchial fistula with amplatzer vascular plug. Ann Thorac Surg. 2015;99:1453.
401. Vivacqua A, Malankar D, Idrees JJ, et al. Endoscopic repair of recurrent tracheoesophageal fistula with an atrial septal occluder device. Ann Thorac Surg. 2016;102:e485–e487.
402. Rodrigues AJ, Scordamaglio PR, Tedde ML, et al. Bronchoscopic closure of tracheoesophageal fistulas. Gastrointest Endosc. 2011;74:1173.
403. Mejia perez LK, Confer B, Veniero J, et al. Closure of a persistent esophagopleural fistula by use of an atrial septal occluder device. VideoGIE. 2016;1:27–28.
404. Kumbhari V, Azola A, Okolo PI, et al. Closure of a chronic tracheoesophageal fistula by use of a cardiac septal occluder. Gastrointest Endosc. 2014;80:332.
405. Rabenstein T, Boosfeld C, Henrich R, et al. First use of ventricular septal defect occlusion device for endoscopic closure of an esophagorespiratory fistula using bronchoscopy and esophagoscopy. Chest. 2006;130:906–909.
406. Kadlec J, Turner K, Van leuven M. Attempted closure of a post-pneumonectomy oesophagopleural fistula with an Amplatzer atrial septal occluder. Interact Cardiovasc Thorac Surg. 2013;16:538–540.
407. Cardoso E, Silva RA, Moreira-dias L. Use of cardiac septal occluder device on upper GI anastomotic dehiscences: a new endoscopic approach (with video). Gastrointest Endosc. 2012;76:1255–1258.
408. Odemis B, Beyazit Y, Torun S, et al. Endoscopic closure of gastrocutaneous fistula with an AMPLATZER(TM) septal occluder device. Therap Adv Gastroenterol. 2015;8:239–242.
409. Cohen-atsmoni S, Tamir A, Avni Y, et al. Endoscopic occlusion of tracheoesophageal fistula in ventilated patients using an Amplatzer septal occluder. Indian J Otolaryngol Head Neck Surg. 2015;67:196–199.
410. Repici A, Presbitero P, Carlino A, et al. First human case of esophagus-tracheal fistula closure by using a cardiac septal occluder (with video). Gastrointest Endosc. 2010;71:867–869.
411. Lee HJ, Jung ES, Park MS, et al. Closure of a gastrotracheal fistula using a cardiac septal occluder device. Endoscopy. 2011;43(suppl 2 UCTN):E53–E54.
412. Wiest R, Tutuian R, Meier B, et al. Use of a cardiac occluder for closure of a complex gastric leak after bariatric surgery. Endoscopy. 2014;46(suppl 1 UCTN):E487–E488.
413. Subtil JC, Valenti V, Cienfuegos JA, et al. Successful endoscopic closure of multiple tracheoesophageal fistulas following implantation of two atrial septal defect occluders. Endoscopy. 2016;48(suppl 1):E346–E347.
414. Fernandez-urien I, Lezaun R, Hernández M, et al. Esophagobronchial fistula closed by a cardiac septal occluder device. Endoscopy. 2016;48(suppl 1):E289–E290.
415. Melmed GY, Kar S, Geft I, et al. A new method for endoscopic closure of gastrocolonic fistula: novel application of a cardiac septal defect closure device (with video). Gastrointest Endosc. 2009;70:542–545.
416. Coppola F, Boccuzzi G, Rossi G, et al. Cardiac septal umbrella for closure of a tracheoesophageal fistula. Endoscopy. 2010;42(suppl 2):E318–E319.
417. Boulougouri K, Theodoropoulos E, Karydas G, et al. Combined endoscopic and percutaneous treatment of a duodenocutaneous fistula using an Amplatzer septal occluder. Cardiovasc Intervent Radiol. 2009;32:356–360.
418. Traina M, Amata M, De monte L, et al. Chronic tracheoesophageal fistula successfully treated using Amplatzer septal occluder. Endoscopy. 2018;50:1236–1237.
419. Green DA, Moskowitz WB, Shepherd RW. Closure of a broncho-to-neoesophageal fistula using an Amplatzer Septal Occluder device. Ann Thorac Surg. 2010;89:2010–2012.
420. Kouklakis G, Zezos P, Liratzopoulos N, et al. Billroth II gastrectomy complicated by gastrojejunocolonic fistulas, treated endoscopically with a cardiac septal defect closure device. Endoscopy. 2010;42(suppl 2):E134–E135.
421. Baron TH. Endoscopic closure of a gastrocolonic fistula using a cardiac ventricular septal defect occlusion device [abstract]. Gastrointest Endosc. 2010;71:AB104.
422. Deslauriers V, Beauchamp A, Garofalo F, et al. Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis. Surg Endosc. 2018;32:601–609.
423. Chang SH, Popov VB, Thompson CC. Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis. Gastrointest Endosc. 2020;91:989–1002.e4.
424. Parikh A, Alley JB, Peterson RM, et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese. Surg Endosc. 2012;26:738–746.
425. Ogra R, Kini GP. Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand. Obes Surg. 2015;25:242–248.
426. Zundel N, Hernandez JD, Galvao neto M, et al. Strictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20:154–158.
427. Werquin C, Caudron J, Mezghani J, et al. Early imaging features after sleeve gastrectomy. J Radiol. 2008;89(pt 1):1721–1728.
428. Vitello DJ, Vitello JM, Beach-bachmann J, et al. Value of routine gastrografin upper gastrointestinal study after sleeve gastrectomy. JAMA Surg. 2019;154:181–182.
429. Alkhatib SG, Levine MS. Gastrobronchial fistula after sleeve gastrectomy: clinical and radiographic findings. Clin Imaging. 2019;53:112–114.
430. Diaz vico T, Elli EF. Utility of immediate postoperative upper gastrointestinal contrast study in bariatric surgery. Obes Surg. 2019;29:1130–1133.
431. Knight J, Krishnaraj A. Utility of 3-week follow-up of upper gastrointestinal study in asymptomatic patients following laparoscopic sleeve gastrectomy. Curr Probl Diagn Radiol. 2020;49:260–265.
432. Alban EAD, García CA, Ospina LM, et al. Imaging after bariatric surgery: when interpretation is a challenge, from normal to abnormal. Obes Surg. 2018;28:2923–2931.
433. De moura EGH, Orso IRB, Aurélio EF, et al. Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2016;12:582–586.
434. Kurien R, Menon S. Balloon dilation in sleeve gastrectomy stenosis: a simple solution to an occasionally tricky problem. Gastrointest Endosc. 2020;91:1003–1004.
435. Yimcharoen P, Heneghan H, Chand B, et al. Successful management of gastrojejunal strictures after gastric bypass: is timing important. Surg Obes Relat Dis. 2012;8:151–157.
436. Brunaldi VO, Galvao Neto M, Zundel N, et al. Isolated sleeve gastrectomy stricture: a systematic review on reporting, workup, and treatment. Surg Obes Relat Dis. 2020;16:955–966.
437. Aryaie AH, Singer JL, Fayezizadeh M, et al. Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS). Surg Endosc. 2017;31:612–617.
438. Jones M, Healey AJ, Efthimiou E. Early use of self-expanding metallic stents to relieve sleeve gastrectomy stenosis after intragastric balloon removal. Surg Obes Relat Dis. 2011;7:e16–e17.