ELECTRONIC IMAGE OF THE MONTH Modified Positioning of a Bariatric Surgery Stent to Manage an Atypical Staple Line Leak After Sleeve Gastrectomy Ana Ponte, Rolando Pinho, and Luísa Proença Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia, Vila Nova Gaia, Portugal
54-year-old woman with morbid obesity underwent a laparoscopic sleeve gastrectomy (SG). On the 11th postoperative day, a staple line leak was diagnosed. Because of hemodynamic instability, laparotomy was performed with drainage of an infected hematoma adjacent to a dehiscence in the distal part of the staple line and a T-tube was placed through the dehiscence. For persistent leakage, endoscopy was performed 2 weeks later showing the T-tube emerging from the anterosuperior bulbar wall. After submucosal contrast injection near the dehiscence, stenting with a coated self-expandable stent (SEMS) designed for SG leaks (HANAROSTENT, ECBB-30-210-090; M.I.Tech, Co., Ltd, Seoul, Korea) was planned. This SEMS has a proximal radiopaque mark to guide its release in the proximal part of the staple line where leaks are more common. Because of the atypical location of the dehiscence, a different technique of positioning independent from the proximal mark was adopted, deploying the SEMS upward from the second part of the duodenum. Four weeks later, the SEMS was removed under fluoroscopic guidance using the invagination method by pulling the distal lasso through the interior of the stent, leading to its internal eversion (Figure A). A large ulcer was identified in the anterosuperior duodenal bulb wall
A
after retroflexion of the scope (Figure B), but the leak was closed because there was no extravasation of contrast in the duodenum (Figure C). Laparoscopic SG is a new surgical procedure in morbid obesity.1,2 Its most serious complication is staple line leak, typically occurring in the gastroesophageal junction.1–3 Management depends on clinical presentation; surgical treatment is indicated in unstable patients.1–3 After controlling sepsis, efforts must focus on closing the dehiscence.2 Covered stents create a physical barrier that allows healing of the dehiscence.3 Although successful in 88% of patients, the main limitations are distal migration and mucosal hypertrophy.2,3 This stent is designed specifically for better adjustment to the SG anatomy and is fully covered, which prevents mucosal hypertrophy. Moreover, although this stent is designed for proximal staple line leaks, it also may be useful for leaks in other locations, as illustrated in this case.
References 1.
Márquez MF, Ayza MF, Lozano RB, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg 2010;20: 1306–1311.
Clinical Gastroenterology and Hepatology 2015;13:e23–e24
ELECTRONIC IMAGE OF THE MONTH, continued 2.
de Aretxabala X, Leon J, Wiedmaier G, et al. Gastric leak after sleeve gastrectomy: analysis of its management. Obes Surg 2011;21:1232–1237.
3.
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.
e24
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.10.033
54-year-old woman with morbid obesity underwent a laparoscopic sleeve gastrectomy (SG). On the 11th postoperative day, a staple line leak was diagnosed. Because of hemodynamic instability, laparotomy was performed with drainage of an infected hematoma adjacent to a dehiscence in the distal part of the staple line and a T-tube was placed through the dehiscence. For persistent leakage, endoscopy was performed 2 weeks later showing the T-tube emerging from the anterosuperior bulbar wall. After submucosal contrast injection near the dehiscence, stenting with a coated self-expandable stent (SEMS) designed for SG leaks (HANAROSTENT, ECBB-30-210-090; M.I.Tech, Co., Ltd, Seoul, Korea) was planned. This SEMS has a proximal radiopaque mark to guide its release in the proximal part of the staple line where leaks are more common. Because of the atypical location of the dehiscence, a different technique of positioning independent from the proximal mark was adopted, deploying the SEMS upward from the second part of the duodenum. Four weeks later, the SEMS was removed under fluoroscopic guidance using the invagination method by pulling the distal lasso through the interior of the stent, leading to its internal eversion (Figure A). A large ulcer was identified in the anterosuperior duodenal bulb wall
A
after retroflexion of the scope (Figure B), but the leak was closed because there was no extravasation of contrast in the duodenum (Figure C). Laparoscopic SG is a new surgical procedure in morbid obesity.1,2 Its most serious complication is staple line leak, typically occurring in the gastroesophageal junction.1–3 Management depends on clinical presentation; surgical treatment is indicated in unstable patients.1–3 After controlling sepsis, efforts must focus on closing the dehiscence.2 Covered stents create a physical barrier that allows healing of the dehiscence.3 Although successful in 88% of patients, the main limitations are distal migration and mucosal hypertrophy.2,3 This stent is designed specifically for better adjustment to the SG anatomy and is fully covered, which prevents mucosal hypertrophy. Moreover, although this stent is designed for proximal staple line leaks, it also may be useful for leaks in other locations, as illustrated in this case.
References 1.
Márquez MF, Ayza MF, Lozano RB, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg 2010;20: 1306–1311.
Clinical Gastroenterology and Hepatology 2015;13:e23–e24
ELECTRONIC IMAGE OF THE MONTH, continued 2.
de Aretxabala X, Leon J, Wiedmaier G, et al. Gastric leak after sleeve gastrectomy: analysis of its management. Obes Surg 2011;21:1232–1237.
3.
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.
e24
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.10.033
