ORCP-408; No. of Pages 6
ARTICLE IN PRESS
Obesity Research & Clinical Practice (2014) xxx, xxx.e1—xxx.e6
CASE REPORT
Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy Shirley Yuk-Wah Liu, Simon Kin-Hung Wong, Enders Kwok-Wai Ng ∗ Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China Received 30 September 2014 ; received in revised form 15 November 2014; accepted 28 November 2014
KEYWORDS Bariatric surgery; Endoscopy; Sleeve gastrectomy; Gastric fistula; Stents
The management of gastric leak after laparoscopic sleeve gastrecSummary tomy (LSG) can be complex and challenging. Whilst operative interventions are mostly complicated and reserved for unstable or refractory cases, endoscopic selfexpandable metal stenting (SEMS) is increasingly preferred as a safer treatment option. Yet, SEMS carries the problems of frequent stent migration and inconsistent healing as ordinary SEMS is designed mainly for stenotic disease. We hereby present two cases of early and chronic post-LSG leakage that were respectively failed to be treated by surgery and ordinary SEMS but were successfully managed by a dedicated extra-long oesophago-gastro-duodenal stent. In oesophago-gastro-duodenal stenting, the characteristics of extra-long stent length allow total gastric exclusion between the mid-oesophagus and the first part of duodenum to prevent stent migration and to equalise high pressure gradient within the gastric sleeve to promote fistula healing. © 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Introduction Gastric leak is one of the most problematic complications after laparoscopic sleeve gastrectomy ∗
Corresponding author. Tel.: +852 26322627; fax: +852 26377974. E-mail address: [email protected] (E.K.-W. Ng).
(LSG). Although the estimated incidence is only 1.1—2.2%, its management can be complex and challenging [1,2]. Gastric leaks have been broadly classified into acute, early, late and chronic types according to the timing of presentation [3]. Acute leak is leak that occurs within the first 7 days of operation while early leak occurs from 1 week to 6 weeks of LSG. When leak occurs after
http://dx.doi.org/10.1016/j.orcp.2014.11.007 1871-403X/© 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
ORCP-408; No. of Pages 6
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Figure 1 (a) CT image at presentation showing loculated abscess and gas collection adjacent to staple line; and (b) CT image showing resolved collection 6 weeks after MegaTM stent insertion.
6 weeks, it is called late leak. Chronic leak refers to leak that occurs after 12 weeks of LSG [3]. We hereby report two cases of early and chronic gastric leaks that were respectively failed to be resolved with surgical repair and ordinary self-expandable metal stent (SEMS) but were managed successfully with the novel oesophago-gastro-duodenal stenting.
Case presentation Patient 1: early leak A 51-year-old lady with body-mass-index of 32 kg/m2 underwent LSG in another hospital for the management of morbid obesity and metabolic syndrome. Her operation was complicated with early gastric leak at the proximal staple line on postoperative day 10. She was treated with emergency laparotomy, sutured repair of the leakage site plus omental patch reinforcement, placement of silicone drain, and feeding jejunostomy for enteral nutrition. Nine days after laparotomy, ongoing leakage was suspected as there was continuous turbid output from the drain. She was then transferred to our unit for further care. Immediate computed tomography (CT) scan confirmed contrast leakage next to the oesophago-gastric junction (EGJ) and adjacent abscess collection (Fig. 1). She was treated with broad spectrum parenteral antibiotics and image-guided percutaneous pigtail drainage of the abscess. After initial stabilisation, oesophagogastroduodenoscopy (EGD) was performed and showed a 5 mm fistula opening at the proximal staple line immediately below EGJ (Fig. 2). There was neither gastric
tube stenosis nor pyloric obstruction. We decided to perform oesophago-gastro-duodenal stenting using an extra-long self-expandable metal stent (SEMS) — 23 cm-long 22 mm-wide Niti-STM MegaTM oesophageal covered stent (TaeWoong Medical, South Korea). During the procedure, she was put in supine position under conscious sedation. Using single-channel gastroscope and fluoroscopic guidance, the gastric leakage site was identified and the locations of EGJ and first part of duodenum (D1) were marked with submucosal lipiodol injection. A stiff guidewire was inserted down to distal duodenum and the endoscope was removed over the guidewire. Under fluoroscopic control, the MegaTM stent was inserted over the guidewire and deployed with its distal end kept in place at D1 and its proximal end kept well above EGJ at mid oesophagus (Fig. 3). After stent deployment, the gastroscope was re-inserted and contrast solution was injected into the stent lumen to confirm adequate sealing. Oral diet was resumed after oesophago-gastroduodenal stenting. The pigtail catheter was removed when the abscess resolved and the courses of antibiotics were completed. Six weeks after stenting, a repeat CT scan showed no residual leakage or intra-abdominal collection (Fig. 1). The stent was removed uneventfully by EGD. The gastric fistula was completely healed and no complication occurred.
Patient 2: chronic leak A 49-year-old lady with BMI of 32 kg/m2 received LSG six months ago in another hospital for the management of morbid obesity and metabolic
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
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Figure 2 EGD and fluoroscopy images showing gastric leak at proximal staple line.
syndrome. She presented with an 8 cm liver abscess that was treated with ultrasound-guided pigtail drainage and antibiotics. A whole-body gallium scan aiming to delineate the cause of liver abscess revealed an intense focus uptake at the left
Figure 3 Oesophago-gastro-duodenal stenting using a 23 cm-long 22 mm-wide Niti-STM MegaTM oesophageal covered stent deploying between the mid-oesophagus and the first part of duodenum.
subdiaphragmatic region immediately posterior to the proximal gastric staple line (Fig. 4). A chronic gastric leak was suspected and she was transferred to our unit for management. Subsequent EGD confirmed a chronic gastric fistula at the proximal staple line. No gastric tube stenosis or pyloric obstruction was found but twisting of the gastric tube along the antral-body axis was noted that caused secondary dilatation of the proximal gastric tube. She was treated initially with the placement of SEMS (12 cm-long, 22 mm-wide NitiSTM fully covered oesophageal stent, TaeWoong Medical, South Korea) across EGJ but was complicated with recurrent stent migration despite anchorage with endoclips. Although re-anchorage by suture fixation using OverstitchTM Endoscopic Suturing System (Apollo Endosurgery, Texas, United States) could successfully prevent further stent migration, there was persistent contrast leakage at the fistula site upon repeat CT scan. Eventually, we inserted a 23 cm-long 22 mm-wide Niti-STM MegaTM oesophageal covered stent (TaeWoong Medical, South Korea) for oesophago-gastro-duodenal stenting in a similar fashion described above. Oral intake was resumed after stenting. The stent was kept in place for 6 weeks until repeat CT scan showing no residual contrast leakage or fluid re-collection (Fig. 4). The stent was removed by EGD and the gastric fistula was found to be completely healed. No untoward complication occurred in this patient.
Discussion Gastric leaks after LSG occur as a result of impaired staple ling healing. Multifactorial causes had been
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
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Figure 4 (a) CT and gallium scan images at presentation showing large liver abscess and focus uptake at left subdiaphragmatic region next to staple line; and (b) CT image showing resolution of abscess collection and leakage 6 weeks after MegaTM stent insertion.
proposed and can be broadly classified into mechanical, vascular and pressure theories. Mechanical cause refers to primary mechanical failure of surgical staples. Because of the unpredictability of staple failure, many surgeons advocated staple line reinforcement such as oversewing or buttressing with various materials [2,4]. However, controversy existed regarding the benefits of staple line reinforcement. A systematic review on over 100 studies suggested that staple line reinforcement had no impact on the leak rate [2]. Another recent systematic review contrarily reported that reinforcement by absorbable polymer membrane had a significantly lower leak rate than oversewing, non-absorbable bovine pericardial strips or no reinforcement [4]. In vascular theory, impaired perfusion to the gastric tube was proposed to be a contributing factor [5]. Majority of gastric leaks occurred in the proximal third of the staple line because vascular supply from one or more branches of the left gastric artery was interrupted during LSG [6]. In pressure theory, impaired tissue healing at the staple line occurred as a result of high pressure environment generated within the proximal gastric tube [7]. Pyloric obstruction and sleeve stricture were common contributing factors [7]. Similarly, the use of small-sized bougie during sleeve transection had been attributed to higher leak rates for the same mechanism [2,8]. Review of 32 studies by Yuval et al. found a significant increase in leak rate from 0.92% to 2.67% when bougie size smaller than 40Fr was used [8]. The management of gastric leaks can be complex and challenging. The administration of broad spectrum antibiotics, high-dose proton pump inhibitors, drainage of abscess collection and nutritional
support are the cornerstones to initial stabilisation. Different definitive treatment strategies including operative and endoscopic interventions can be applied to early and chronic gastric leaks [9]. In early leak, operative intervention by peritoneal lavage and primary repair with or without buttressing materials was recommended for immediate control although the rates of recurrent or non-healing fistulas were disappointingly high [9]. In stable non-septic patients with early leak, nonoperative strategy could be judiciously adopted. Early EGD or contrast studies should be performed to evaluate for the leakage site and associated sleeve stricture or stenosis. Different endoscopic treatments had been reported including direct endoscopic suture-closure, clipping, fibrin glue sealing and vascular plug application but their fistula healing rates were variable and inconsistent [9—12]. Other authors suggested the use of endoscopic pigtail stent insertion through the leakage site for internal drainage plus nasojejunal tube feeding to control leakage but repeated endoscopic sessions were required [13]. SEMS was an increasingly appealing option for its higher fistula healing rate of up to 50—100% and yet lower morbidities and invasiveness [9,14—18]. It could help diverting the intraluminal contents, re-establishing gastrointestinal continuity, allowing early re-introduction of enteral feeding, and promoting fistula healing. However, stent migration was a problematic concern as these prostheses were designed mainly for stenotic disease instead of leakage. The reported incidence of stent migration for gastric leak was up to 47—54% [14—18]. The need of repeated endoscopic procedures for stent repositioning or replacement could be bothersome to both patients
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
ORCP-408; No. of Pages 6
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Novel oesophago-gastro-duodenal stenting for gastric leaks Table 1
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Comparison between oesophago-gastro-duodenal stent and ordinary SEMS. Oesophago-gastro-duodenal stent
Ordinary SEMS
Pros
• Extra-long stent length prevents distal stent migration • Total gastric exclusion allows equalisation of unfavourable high pressure gradient within gastric sleeve tube • Wider stent diameter allows precise stent sealing to promote fistula healing
• Potentially lower cost • Less distressing post-procedure chest pain • Shorter stent length avoids symptoms of severe nausea and vomiting • Anti-reflux variants available • Many different stent choices available on the market
Cons
• Higher cost • Wider stent diameter causes more post-procedure chest pain • Longer stent length causes more post-procedure nausea and vomiting • Very limited stent choices on the market
• Frequent stent migration • Shorter stent length fails to alleviate hyper-pressure problem within gastric sleeve tube • Less reliable fistula healing rate
SEMS, self-expandable metal stent.
and clinicians. However, as demonstrated in our cases, the concept of oesophago-gastro-duodenal stenting can actually tackle both gastric leak and stent migration in one goal. The extra-long stent length of 18 cm or 23 cm allows secure stent placement between mid-oesophagus and D1 to minimise significant distal migration. Besides, the wider diameter of 22 mm, 24 mm or 28 mm allows better adherence between the stent and the gastric wall to promote precise sealing. Moreover, its metal mesh layer is specially designed with soft and flexible characteristics that enable better adaptation to the acute anatomy after LSG. A comparison between oesophago-gastro-duodenal stent and ordinary SEMS is summarised in Table 1. For chronic leaks, similar endoscopic treatment options especially SEMS were commonly attempted but failed healing was common due to chronic fistula formation [17,18]. Gastric tube hyper-pressure was the major factor perpetuating chronic leakage. As ordinary SEMS placing across EGJ alone could hardly alleviate the hyper-pressure problem, fistula healing often failed to occur [9,18]. More aggressive operative approaches had been proposed for better healing rates, including proximal or total gastrectomy with Roux-en-Y oesophagojejunal anastomosis, Roux-en-Y fistulojejunostomy without gastrectomy, and controlled fistula with T-tube gastrostomy [19—22]. However, all these approaches were often associated with higher morbidities and were thus reserved for unstable patients or refractory fistulas. In oesophago-gastroduodenal stenting with extra-long SEMS, total gastric exclusion was possible to equalise high pressure gradient within gastric tube and to relieve potential unfavourable hyper-pressure factors like
pyloric obstruction, sleeve stenosis or gastric tube twisting. Spontaneous fistula healing after extra-long SEMS could become confidently possible without the need of aggressive surgery. In conclusion, total gastric exclusion with oesophago-gastro-duodenal stenting in our cases resulted in safe and successful healing of both early and chronic gastric leaks after LSG. Further largescale prospective studies are required to explore its difference with other treatment strategies for post-LSG leaks.
Conflict of interest None declared.
References [1] Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg 2013;23(12):2013—7. [2] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 2013;257(2):231—7. [3] Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, Basso N, 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(1):8—19. [4] 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(4):713—23. [5] Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M. The science of stapling and leaks. Obes Surg 2004;14(10):1290—8.
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
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[6] Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4888 patients. Surg Endosc 2012;26(6):1509—15. [7] Yehoshua RT, Eidelman LA, Stein M, Fichman S, Mazor A, Chen J, et al. Laparoscopic sleeve gastrectomy — volume and pressure assessment. Obes Surg 2008;18(9): 1083—8. [8] Yuval JB, Mintz Y, Cohen MJ, Rivkind AI, Elazary R. The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy: is there an ideal bougie size? Obes Surg 2013;23(10):1685—91. [9] Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2834 patients. Surg Endosc 2013;27(1):240—5. [10] Mercky P, Gonzalez JM, Aimore Bonin E, Emungania O, Brunet J, Grimaud JC, et al. Usefulness of over-the-scope clipping system for closing digestive fistulas. Dig Endosc 2014, http://dx.doi.org/10.1111/den.12295 [Epub ahead of print]. [11] Papavramidis TS, Kotzampassi K, Kotidis E, Eleftheriadis EE, Papavramidis ST. Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch. J Gastroenterol Hepatol 2008;23(12):1802—5. [12] Kim Z, Kim YJ, Kim YJ, Goo DE, Cho JY. Successful management of staple line leak after laparoscopic sleeve gastrectomy with vascular plug and covered stent. Surg Laparosc Endosc Percutan Tech 2011;21(4):e206—8. [13] Donatelli G, Ferretti S, Vergeau BM, Dhumane P, Dumont JL, Derhy S, et al. Endoscopic Internal Drainage with Enteral Nutrition (EDEN) for treatment of leaks following sleeve gastrectomy. Obes Surg 2014;24(8):1400—7. [14] Serra C, Baltasar A, Andreo L, Pérez N, Bou R, Bengochea M, et al. Treatment of gastric leaks with coated
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self-expanding stent after sleeve gastrectomy. Obes Surg 2007;17(7):866—72. Fukumoto R, Orlina J, McGinty J, Teixeira J. Use of Polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery. Surg Obes Relat Dis 2007;3(1):68—71. Slim R, Smayra T, Chakhtoura G, Noun R. Endoscopic stenting of gastric staple line leak following sleeve gastrectomy. Obes Surg 2013;23(11):1942—5. 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(5):935—8. Puig CA, Waked TM, Baron Sr TH, Wong Kee Song LM, Gutierrez J, Sarr MG. 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(4):613—7. Thompson 3rd CE, Ahmad H, Lo Menzo E, Szomstein S, Rosenthal RJ. Outcomes of laparoscopic proximal gastrectomy with esophagojejunal reconstruction for chronic staple line disruption after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10(3):455—9. Ben Yaacov A, Sadot E, Ben David M, Wasserberg N, Keidar A. Laparoscopic total gastrectomy with Roux-y esophagojejunostomy for chronic gastric fistula after laparoscopic sleeve gastrectomy. Obes Surg 2014;24(3):425—9. Chour M, Alami RS, Sleilaty F, Wakim R. The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks. Surg Obes Relat Dis 2014;10(1): 106—10. Court I, Wilson A, Benotti P, Szomstein S, Rosenthal RJ. T-tube gastrostomy as a novel approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case report and review of the literature. Obes Surg 2010;20(4):519—22.
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Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
ARTICLE IN PRESS
Obesity Research & Clinical Practice (2014) xxx, xxx.e1—xxx.e6
CASE REPORT
Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy Shirley Yuk-Wah Liu, Simon Kin-Hung Wong, Enders Kwok-Wai Ng ∗ Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China Received 30 September 2014 ; received in revised form 15 November 2014; accepted 28 November 2014
KEYWORDS Bariatric surgery; Endoscopy; Sleeve gastrectomy; Gastric fistula; Stents
The management of gastric leak after laparoscopic sleeve gastrecSummary tomy (LSG) can be complex and challenging. Whilst operative interventions are mostly complicated and reserved for unstable or refractory cases, endoscopic selfexpandable metal stenting (SEMS) is increasingly preferred as a safer treatment option. Yet, SEMS carries the problems of frequent stent migration and inconsistent healing as ordinary SEMS is designed mainly for stenotic disease. We hereby present two cases of early and chronic post-LSG leakage that were respectively failed to be treated by surgery and ordinary SEMS but were successfully managed by a dedicated extra-long oesophago-gastro-duodenal stent. In oesophago-gastro-duodenal stenting, the characteristics of extra-long stent length allow total gastric exclusion between the mid-oesophagus and the first part of duodenum to prevent stent migration and to equalise high pressure gradient within the gastric sleeve to promote fistula healing. © 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Introduction Gastric leak is one of the most problematic complications after laparoscopic sleeve gastrectomy ∗
Corresponding author. Tel.: +852 26322627; fax: +852 26377974. E-mail address: [email protected] (E.K.-W. Ng).
(LSG). Although the estimated incidence is only 1.1—2.2%, its management can be complex and challenging [1,2]. Gastric leaks have been broadly classified into acute, early, late and chronic types according to the timing of presentation [3]. Acute leak is leak that occurs within the first 7 days of operation while early leak occurs from 1 week to 6 weeks of LSG. When leak occurs after
http://dx.doi.org/10.1016/j.orcp.2014.11.007 1871-403X/© 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
ORCP-408; No. of Pages 6
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Figure 1 (a) CT image at presentation showing loculated abscess and gas collection adjacent to staple line; and (b) CT image showing resolved collection 6 weeks after MegaTM stent insertion.
6 weeks, it is called late leak. Chronic leak refers to leak that occurs after 12 weeks of LSG [3]. We hereby report two cases of early and chronic gastric leaks that were respectively failed to be resolved with surgical repair and ordinary self-expandable metal stent (SEMS) but were managed successfully with the novel oesophago-gastro-duodenal stenting.
Case presentation Patient 1: early leak A 51-year-old lady with body-mass-index of 32 kg/m2 underwent LSG in another hospital for the management of morbid obesity and metabolic syndrome. Her operation was complicated with early gastric leak at the proximal staple line on postoperative day 10. She was treated with emergency laparotomy, sutured repair of the leakage site plus omental patch reinforcement, placement of silicone drain, and feeding jejunostomy for enteral nutrition. Nine days after laparotomy, ongoing leakage was suspected as there was continuous turbid output from the drain. She was then transferred to our unit for further care. Immediate computed tomography (CT) scan confirmed contrast leakage next to the oesophago-gastric junction (EGJ) and adjacent abscess collection (Fig. 1). She was treated with broad spectrum parenteral antibiotics and image-guided percutaneous pigtail drainage of the abscess. After initial stabilisation, oesophagogastroduodenoscopy (EGD) was performed and showed a 5 mm fistula opening at the proximal staple line immediately below EGJ (Fig. 2). There was neither gastric
tube stenosis nor pyloric obstruction. We decided to perform oesophago-gastro-duodenal stenting using an extra-long self-expandable metal stent (SEMS) — 23 cm-long 22 mm-wide Niti-STM MegaTM oesophageal covered stent (TaeWoong Medical, South Korea). During the procedure, she was put in supine position under conscious sedation. Using single-channel gastroscope and fluoroscopic guidance, the gastric leakage site was identified and the locations of EGJ and first part of duodenum (D1) were marked with submucosal lipiodol injection. A stiff guidewire was inserted down to distal duodenum and the endoscope was removed over the guidewire. Under fluoroscopic control, the MegaTM stent was inserted over the guidewire and deployed with its distal end kept in place at D1 and its proximal end kept well above EGJ at mid oesophagus (Fig. 3). After stent deployment, the gastroscope was re-inserted and contrast solution was injected into the stent lumen to confirm adequate sealing. Oral diet was resumed after oesophago-gastroduodenal stenting. The pigtail catheter was removed when the abscess resolved and the courses of antibiotics were completed. Six weeks after stenting, a repeat CT scan showed no residual leakage or intra-abdominal collection (Fig. 1). The stent was removed uneventfully by EGD. The gastric fistula was completely healed and no complication occurred.
Patient 2: chronic leak A 49-year-old lady with BMI of 32 kg/m2 received LSG six months ago in another hospital for the management of morbid obesity and metabolic
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
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Figure 2 EGD and fluoroscopy images showing gastric leak at proximal staple line.
syndrome. She presented with an 8 cm liver abscess that was treated with ultrasound-guided pigtail drainage and antibiotics. A whole-body gallium scan aiming to delineate the cause of liver abscess revealed an intense focus uptake at the left
Figure 3 Oesophago-gastro-duodenal stenting using a 23 cm-long 22 mm-wide Niti-STM MegaTM oesophageal covered stent deploying between the mid-oesophagus and the first part of duodenum.
subdiaphragmatic region immediately posterior to the proximal gastric staple line (Fig. 4). A chronic gastric leak was suspected and she was transferred to our unit for management. Subsequent EGD confirmed a chronic gastric fistula at the proximal staple line. No gastric tube stenosis or pyloric obstruction was found but twisting of the gastric tube along the antral-body axis was noted that caused secondary dilatation of the proximal gastric tube. She was treated initially with the placement of SEMS (12 cm-long, 22 mm-wide NitiSTM fully covered oesophageal stent, TaeWoong Medical, South Korea) across EGJ but was complicated with recurrent stent migration despite anchorage with endoclips. Although re-anchorage by suture fixation using OverstitchTM Endoscopic Suturing System (Apollo Endosurgery, Texas, United States) could successfully prevent further stent migration, there was persistent contrast leakage at the fistula site upon repeat CT scan. Eventually, we inserted a 23 cm-long 22 mm-wide Niti-STM MegaTM oesophageal covered stent (TaeWoong Medical, South Korea) for oesophago-gastro-duodenal stenting in a similar fashion described above. Oral intake was resumed after stenting. The stent was kept in place for 6 weeks until repeat CT scan showing no residual contrast leakage or fluid re-collection (Fig. 4). The stent was removed by EGD and the gastric fistula was found to be completely healed. No untoward complication occurred in this patient.
Discussion Gastric leaks after LSG occur as a result of impaired staple ling healing. Multifactorial causes had been
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
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Figure 4 (a) CT and gallium scan images at presentation showing large liver abscess and focus uptake at left subdiaphragmatic region next to staple line; and (b) CT image showing resolution of abscess collection and leakage 6 weeks after MegaTM stent insertion.
proposed and can be broadly classified into mechanical, vascular and pressure theories. Mechanical cause refers to primary mechanical failure of surgical staples. Because of the unpredictability of staple failure, many surgeons advocated staple line reinforcement such as oversewing or buttressing with various materials [2,4]. However, controversy existed regarding the benefits of staple line reinforcement. A systematic review on over 100 studies suggested that staple line reinforcement had no impact on the leak rate [2]. Another recent systematic review contrarily reported that reinforcement by absorbable polymer membrane had a significantly lower leak rate than oversewing, non-absorbable bovine pericardial strips or no reinforcement [4]. In vascular theory, impaired perfusion to the gastric tube was proposed to be a contributing factor [5]. Majority of gastric leaks occurred in the proximal third of the staple line because vascular supply from one or more branches of the left gastric artery was interrupted during LSG [6]. In pressure theory, impaired tissue healing at the staple line occurred as a result of high pressure environment generated within the proximal gastric tube [7]. Pyloric obstruction and sleeve stricture were common contributing factors [7]. Similarly, the use of small-sized bougie during sleeve transection had been attributed to higher leak rates for the same mechanism [2,8]. Review of 32 studies by Yuval et al. found a significant increase in leak rate from 0.92% to 2.67% when bougie size smaller than 40Fr was used [8]. The management of gastric leaks can be complex and challenging. The administration of broad spectrum antibiotics, high-dose proton pump inhibitors, drainage of abscess collection and nutritional
support are the cornerstones to initial stabilisation. Different definitive treatment strategies including operative and endoscopic interventions can be applied to early and chronic gastric leaks [9]. In early leak, operative intervention by peritoneal lavage and primary repair with or without buttressing materials was recommended for immediate control although the rates of recurrent or non-healing fistulas were disappointingly high [9]. In stable non-septic patients with early leak, nonoperative strategy could be judiciously adopted. Early EGD or contrast studies should be performed to evaluate for the leakage site and associated sleeve stricture or stenosis. Different endoscopic treatments had been reported including direct endoscopic suture-closure, clipping, fibrin glue sealing and vascular plug application but their fistula healing rates were variable and inconsistent [9—12]. Other authors suggested the use of endoscopic pigtail stent insertion through the leakage site for internal drainage plus nasojejunal tube feeding to control leakage but repeated endoscopic sessions were required [13]. SEMS was an increasingly appealing option for its higher fistula healing rate of up to 50—100% and yet lower morbidities and invasiveness [9,14—18]. It could help diverting the intraluminal contents, re-establishing gastrointestinal continuity, allowing early re-introduction of enteral feeding, and promoting fistula healing. However, stent migration was a problematic concern as these prostheses were designed mainly for stenotic disease instead of leakage. The reported incidence of stent migration for gastric leak was up to 47—54% [14—18]. The need of repeated endoscopic procedures for stent repositioning or replacement could be bothersome to both patients
Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
ORCP-408; No. of Pages 6
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Novel oesophago-gastro-duodenal stenting for gastric leaks Table 1
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Comparison between oesophago-gastro-duodenal stent and ordinary SEMS. Oesophago-gastro-duodenal stent
Ordinary SEMS
Pros
• Extra-long stent length prevents distal stent migration • Total gastric exclusion allows equalisation of unfavourable high pressure gradient within gastric sleeve tube • Wider stent diameter allows precise stent sealing to promote fistula healing
• Potentially lower cost • Less distressing post-procedure chest pain • Shorter stent length avoids symptoms of severe nausea and vomiting • Anti-reflux variants available • Many different stent choices available on the market
Cons
• Higher cost • Wider stent diameter causes more post-procedure chest pain • Longer stent length causes more post-procedure nausea and vomiting • Very limited stent choices on the market
• Frequent stent migration • Shorter stent length fails to alleviate hyper-pressure problem within gastric sleeve tube • Less reliable fistula healing rate
SEMS, self-expandable metal stent.
and clinicians. However, as demonstrated in our cases, the concept of oesophago-gastro-duodenal stenting can actually tackle both gastric leak and stent migration in one goal. The extra-long stent length of 18 cm or 23 cm allows secure stent placement between mid-oesophagus and D1 to minimise significant distal migration. Besides, the wider diameter of 22 mm, 24 mm or 28 mm allows better adherence between the stent and the gastric wall to promote precise sealing. Moreover, its metal mesh layer is specially designed with soft and flexible characteristics that enable better adaptation to the acute anatomy after LSG. A comparison between oesophago-gastro-duodenal stent and ordinary SEMS is summarised in Table 1. For chronic leaks, similar endoscopic treatment options especially SEMS were commonly attempted but failed healing was common due to chronic fistula formation [17,18]. Gastric tube hyper-pressure was the major factor perpetuating chronic leakage. As ordinary SEMS placing across EGJ alone could hardly alleviate the hyper-pressure problem, fistula healing often failed to occur [9,18]. More aggressive operative approaches had been proposed for better healing rates, including proximal or total gastrectomy with Roux-en-Y oesophagojejunal anastomosis, Roux-en-Y fistulojejunostomy without gastrectomy, and controlled fistula with T-tube gastrostomy [19—22]. However, all these approaches were often associated with higher morbidities and were thus reserved for unstable patients or refractory fistulas. In oesophago-gastroduodenal stenting with extra-long SEMS, total gastric exclusion was possible to equalise high pressure gradient within gastric tube and to relieve potential unfavourable hyper-pressure factors like
pyloric obstruction, sleeve stenosis or gastric tube twisting. Spontaneous fistula healing after extra-long SEMS could become confidently possible without the need of aggressive surgery. In conclusion, total gastric exclusion with oesophago-gastro-duodenal stenting in our cases resulted in safe and successful healing of both early and chronic gastric leaks after LSG. Further largescale prospective studies are required to explore its difference with other treatment strategies for post-LSG leaks.
Conflict of interest None declared.
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Please cite this article in press as: Liu SY-W, et al. Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.orcp.2014.11.007
