Endoscopic management of bariatric surgery complications: long-term results of 830 consecutive patients in a single center experience

Introduction: Surgery is the gold standard treatment of morbid obesity and its related co-morbidities. However early or late surgical related adverse events(AE) occurs in 4 to 25% of patients requiring, in most cases, re- interventions. Endoscopy is an effective treatment especially if it is per- formed soon after occurrence of AE. However a comprehensive evalua- tion of long-term results and need for revisional surgery after endoscopic management is lacking. aims & Methods: The aim of this study is to report overall results and long- term outcomes of patients underwent to endoscopic management for AE following bariatric surgery in a tertiary interventional endoscopic center. From January2013 to April2019, 830 consecutive patients(640F), average age 44(17 - 72), underwent upper GI endoscopy for suspected AE following obesity surgery. 651 patients underwent Sleeve Gastrectomy, 167 gastric-by-pass(98 Roux- en-Y and 69 Omega)(GBP)and 12 had lap-band. 168 patients presented an AE after revisional bariatric surgery. 358 patients were addressed for sepsis due to supposed leak(extravasation of medium contrast). 226 patients presented dysphagia due to GI stenosis. 201 subjects presented fistula(abnormal communication between two re- epithelized structures or skin due to previous placement of surgical drain- age). 28 patients had a perigastric intra-abdominal collection. 12 patients had partial intragastric migration of gastric band. 5 presented weight regain following GBP for enlargement of G-J anas- tomosis. Endoscopic management according to the different type of AE were one or an association of the following: endoscopic internal drain- age, septotomy, stenting with Lumen apposed metal stent, Argon plasma coagulation(APC) anastomotic remodeling and trans-oral lap band abla- tion. Clinical success was defined as follows: leak and fistula: no medium con- trast extravasation, no chemistry tests alterations no need for prolonged antibiotics therapy. Stricture: adequate passage of medium contrast at swallow study or easy crossing of the stricture with a standard gastro- scope. Lap band migration:uneventful removal. Loss of excess weight after G-J anastomotic remodeling with APC. Long term clinical success was con- sidered after a minimum follow up of more than 18 months. results: 89 patients underwent endoscopy after one week from index surgery(5,13 ± 1,92days), 451 between 8 and 42days(19,63 ± 9,17), 93 patients between 43 and 91days(60,34 ± 13,07) and 197 after more than 91days(854,93 ± 1170,37). Overall mean period was of 223days(0-2100) from index surgery. 70 patients(8.4%) presented normal findings at upper endoscopy. An average of 6 endoscopic sessions(1-31) were needed to achieve AE reso- lution in 72%(598) of patients. At long follow up (more than 18 months) 16%(96 out 598) of patients healed were lost whereas. 8%(66) are still under treatment. Overall mortality was of 0,6%(5 out 830) whereas overall AE related to en- doscopic treatment was of 2%(15)namely bleeding, stent migration with/ or perforation. 3 patients with perforation required emergency surgery. 11.%(91 patients) underwent revisional surgery either for endoscopic treat- ment failure or poor quality of life after an average of 331days(15 - 1400). conclusion: According to this large case series endoscopy plays a pivotal role in the management of AE following bariatric surgery guaranteeing good results with low morbidity and mortality rates avoiding emergency surgery in 65% of cases. However several endoscopic sessions are needed. Long-term follow up showed that 11% of patients require, revisional sur- gery, either in case of endoscopic clinical success

Long-term placement of lumen apposing metal stent for EUS guided duodeno and jejuno-jejunal anastomosis for direct access to excluded jejunal limb

Background: Management of biliary disorders in patients with altered anatomy may be challenging. EUS-guided gastrointestinal anastomosis using lumen apposing metal stent (LAMS) have been introduced to allow endoscopic retrograde cholangiography (ERC) in such cases. However the appropriate stent indwelling time is still uncertain. We report long-term LAMS deployment after duodeno-jejunal or jejuno-jejunal anastomosis (EUS-DJA) to allow endoscopic re-interventions in case of recurrences. Methods: 11 consecutive patients underwent to EUS-DJA with long standing LAMS between January 2017 and December 2018. ERC treatment was carried out over a 12 months period with multiple endoscopic sessions across DJA. Results: Technical success was 91% (10/11 pts) for EUS-DJA and 100% for ERC. Four patients presented stricture recurrence after an average of 489±31.7 days from the end of ERC treatment. A novel ERC across LAMS anastomosis was feasible in all cases. At average of 781 days±253 all LAMS are still in place with no evidence of any adverse event. Conclusion: Long-term LAMS placement after EUSDJA may be feasible and safe in order to maintain a direct access to the excluded limb

Une épilepsie… pas très salée!

International audienc

Endoscopic Internal Drainage With Enteral Nutrition (EDEN) for Treatment of Leaks Following Sleeve Gastrectomy

Background: Endoscopic treatment of gastric leaks (GL) following sleeve gastrectomy (SG) involves different techniques; however, standard management is not yet established. We report our experience about endoscopic internal drainage of leaks using pigtail stents coupled with enteral nutrition (EDEN) for 4 to 6 weeks until healing is achieved. Methods: In 21 pts (18 F, 41 years), one or two plastic pigtail stents were delivered across the leak 25.6 days (4-98) post-surgery. In all patients, nasojejunal tube was inserted. Check endoscopy was done at 4 to 6 weeks with either restenting if persistent leak, or removal if no extravasation of contrast in peritoneal cavity, or closure with an Over-the-Scope Clip® (OTSC®) if contrast opacifying the crossing stent without concomitant peritoneal extravasation. Results: Twenty-one out of 21 (100 %) patients underwent check endoscopy at average of 30.15 days (26-45) from stenting. In 7/21 (33.3 %) patients leak sealed, 2/7 needed OTSC®. Second check endoscopy, 26.7 days (25-42) later, showed sealed leak in 10 out 14; 6/10 had OTSC®. Four required restenting. One patient, 28 days later, needed OTSC®. One healed at 135 days and another 180 days after four and seven changes, respectively. One patient is currently under treatment. In 20/21 (95.2 %), GL have healed with EID treatment of 55.5 days (26- 180); all are asymptomatic on a normal diet at average follow-up of 150.3 days (20-276). Conclusions: EDEN is a promising therapeutic approach for treating leaks following SG. Multiple endoscopic sessions may be required