Endoscopic closure techniques of bariatric surgery complications: a meta-analysis.

BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

Use of high-frequency electrical stimulation in gastrocutaneous fistula closure: a case report.

BACKGROUND: Gastrocutaneous fistula is a rare complication following Roux-en-Y gastric bypass, a commonly performed bariatric surgery. While most ECFs respond to conservative management, some do not close despite adequate nutritional support, infection source control, and drainage management. As such, the chronicity of these difficult-to-treat wounds can be physically and economically costly to patients. CASE REPORT: A 53-year-old female with a history of Roux-en-Y gastric bypass developed a gastrocutaneous fistula secondary to a perforated gastrojejunal ulcer, requiring immediate surgical intervention. After being discharged from the hospital, 37 days of conservative management and NPWT did not reduce the size of the fistula tract. To help control the patient's chronic abdominal pain and increase the rate of wound healing, the patient underwent treatment with HFES (20 kHz) delivered using a handheld transcutaneous electrical nerve stimulator. This electrotherapy was found to reduce the majority of the patient's pain within the first treatment session. The patient's fistula also began to decrease in size within 1 week of initiating treatment. CONCLUSION: This case report details the successful closure of a gastrocutaneous fistula after administration of HFES 3 times a week over the course of 25 days. The mechanism of action of HFES and its role in the wound healing process are also discussed.

Fixation of the proximal flange of a lumen-apposing metal stent using a through-the-scope endoscopic suturing system to prevent stent migration in single-session EUS-directed transgastric ERCP: a pilot study.

BACKGROUND AND AIMS: With the global obesity pandemic, clinical scenarios requiring urgent ERCP in patients with gastric bypass surgery are on the rise, and single-session EUS-directed transgastric ERCP (SS-EDGE) can effectively address these technical challenges. The aim of this study was to evaluate and describe the safe and effective use of a through-the-scope endoscopic suturing system for anchoring the lumen-apposing metal stents (LAMSs) during SS-EDGE. METHODS: Six patients with Roux-en-Y gastric bypass (RYGB) underwent SS-EDGE at our center. A through-the-scope endoscopic suturing system was used for anchoring the LAMSs during SS-EDGE. RESULTS: Clinical and technical success was achieved in all 6 patients without any adverse events related to the procedure. No stent migration, pneumoperitoneum, or GI perforation was noted. At the 4-week follow-up, no stent migration was noted, and the through-the-scope suturing system remained anchored. LAMSs along with tacks were removed, and gastric fistulae were successfully closed endoscopically in all patients to prevent weight gain. CONCLUSIONS: Use of through-the-scope endoscopic suturing can be a safe, reliable, and potentially cost-effective novel technique for LAMS fixation to successfully perform SS-EDGE in RYGB patients.

Persistent Ostomy Following Percutaneous Endoscopic Gastrostomy Removal: Treatment Strategies.

PURPOSE OF REVIEW: The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy. RECENT FINDINGS: The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.

Gastrojejunal Fistula Following Gastrostomy Tube.

Gastrostomy tubes are often placed in patients with poor voluntary intake, oropharyngeal dysphagia, or chronic illness to provide definitive nutritional access. Despite the widespread use of gastrostomy tubes, some patients can experience complications associated with this procedure including gastrocolic-cutaneous fistula and dislodgement of gastrostomy tube. This case discusses an instance of gastrojejunal fistula formation over one year after gastrostomy tube placement likely due to tube dislodgement. Imaging showed gastrostomy tube traversing the posterior wall of the stomach and creating a fistula into the jejunum, with the balloon inflated within the jejunum. Gastrostomy tube was removed and replaced, with gastrostomy tube study showing no extravasation of contrast. Patient is now doing well-tolerating tube feeds at goal.

Endoscopic stent placement for the management of gastro-pleural and gastro-cutaneous fistula post laparoscopic sleeve gastrectomy: a case report.

BACKGROUND: Gastro-pleural and gastro-cutaneous fistulae formation are rare yet life-threatening complications post-bariatric surgery. To our knowledge so far only limited cases of gastro-pleural and gastro-cutaneous fistulae post gastric sleeve surgery have been reported in the literature with their corresponding management. Therefore, we are reporting a case of placement of an endoscopic stent in the management of gastro-cutaneous fistula post laparoscopic sleeve gastrectomy. CASE PRESENTATION: A 42 years old Pakistani, female morbidly obese patient, underwent laparoscopic sleeve gastrectomy. Within a week after the procedure, the patient presented with dyspnea. Workup showed a gastric leak for which percutaneous drain placement was done. Later, gastro-pleural and gastro-cutaneous fistulae were formed for which endoscopic fistula closure was done using a metallic stent. CONCLUSION: Endoscopic stent placement is an emerging field and it is considered safe and effective for the management of complications related to bariatric surgery.

Closure of Gastrocutaneous Fistula Following Bariatric Surgery: a Systematic Review.

Gastrocutaneous fistula (GCF) is a devastating complication that can arise after bariatric and metabolic surgery (BMS). This systematic review examines the success rate of closure techniques of GCF. A systematic search was conducted across MEDLINE, Embase and Cochrane databases to identify studies which reported on closure techniques of GCF after BMS in adults. Thirty-three studies (n = 108 patients) were included. Seventeen different techniques were used to close GCF across all studies. The most popular were stents (n = 17), tissue sealants (n = 12) and over-the-scope clips (n = 11). Twenty-one studies used multiple techniques to attempt closure, including endoscopic vacuum therapy and revisional surgery. This systematic review demonstrates current practice focusing on endoscopic methods such as stents and over-the-scope clips, with relative success in closing GCF.

Diagnosis and surgical treatment of cysto-gastric fistula out of an hepatic hydatid cyst. Unusual case.

BACKGROUND: Hydatid cyst is an endemic zoonotic infection that annual incidence ranges from <1 to 200 per 100,000 individuals. The most common complication of hepatic hydatid cyst reported is rupture of the cysts, most commonly intrabiliary rupture. Direct rupture to hollow visceral organs is rarely seen. We describe here an unusual cystogastric fistula in a patient with liver hydatid cyst. CASE PRESENTATION: The 55-year-old male patient presented with right upper quadrant abdominal pain. After radiological imaging studies, the diagnose was of hydatid cyst involving the left lateral segment of the liver ruptured into the gastric lumen and resulted in a cystogastric fistula. Gastroscopy revealed that the cyst and its contents protruding from anterior wall to the gastric lumen. Partial pericystectomy and omentopexy were performed and the gastric wall was primarily repaired. There were no complications in the postoperative period and 3-month follow up. CONCLUSION: This case, to our knowledge, is the first reported case of cystogastric fistula surgically treated in a patient with liver hydatid cyst in the literature. Our clinical experience shows that, although it is a benign disease, complicated hydatid cysts should be evaluated in detail preoperatively, and after the detailed diagnostic work-up, surgical therapy might be planned individually for each case. KEY WORDS: Cysto-gastric fistula, Hydatid Cyst, Liver hydatidosis.

Gastrosplenic Fistula Secondary to Simultaneous Gastric and Splenic Diffuse Large B-Cell Lymphoma.

Gastrosplenic fistula is a rare complication arising mainly secondary to involvement of the stomach or spleen by lymphoma. A delayed diagnosis is associated with high morbidity and mortality. We present a case of gastrosplenic fistula secondary to gastric and splenic involvement by diffuse large B-cell lymphoma with relevant imaging findings. The patient was successfully treated with surgical resection.

Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss.

BACKGROUND: Gastrogastric fistula (GGF) is a rare complication from Roux-en-Y gastric bypass (RYGB). It is a known risk factor associated with weight recidivism and an indication for Bariatric Revisional Surgery (BRS). OBJECTIVES: The primary outcome of this study is to evaluate perioperative outcomes and the long-term total body weight loss (TBWL) outcomes following revision. SETTING: Single Academic Institution, Center of Bariatric Excellence. METHODS: We selected patients who had primary bariatric surgery and BRS from 2003 to 2020, followed by BRS for GGF. Patients' demographics, perioperative outcomes, and TBWL were analyzed. RESULTS: One hundred five patients underwent BRS for GGF. Mean body mass index (BMI) at index operation and revision was 51.6 ± 10.1, and 42.4 ± 11.2 respectively. Ninety percent of patients had open primary RYGB, and 69% had open revisional surgery. The median length of stay after BRS was 3 days. The 30-day reintervention rate was 19%. The 30-day readmission rate was 34%. Of the 77 patients included for weight loss analysis, the mean %TBWL after primary RYGB was 34% ± 14. The total mean %TBWL at the time of revision was 18.8%, translating into a weight regain of 13.6% ± 9.5. The total mean %TBWL after revision was 37.6% ± 11.4, translating into TBWL of 18.8% ± 9.4 after revision when compared to TBWL at revision time. CONCLUSIONS: Our results demonstrate that revision for GGF can be safely performed, however is associated with higher morbidity than primary bariatric surgery. Revision for GGF results in significant long-term weight loss.

Endoscopic management of refractory leak and gastro-cutaneous fistula after laparoscopic sleeve gastrectomy: a randomized controlled trial.

BACKGROUND: Gastro-cutaneous fistula is a rare complication after laparoscopic sleeve gastrectomy (LSG) with incidence of occurrence 1-2%. Most of gastro-cutaneous fistulae do not respond to conservative management and need intervention either surgically or endoscopically. METHODS: This prospective randomized clinical study included referred patients who had LSG performed at our department or other centers, and complicated with post-LSG leak or gastro-cutaneous fistula between December/2019 and March/2021. Included patients were ASA Physical status I-II. Primary and secondary outcomes were recurrence of the fistula and mortality in each group after the intervention during the 18 months follow-up period, respectively. RESULTS: Thirty patients were randomized into two groups: Surgery Group (SG, n = 15) and Endoscopy Group (EG, n = 15). Mean age of patients was 42.3 ± 8.7 and 42.6 ± 8.3 years-old in SG and EG, respectively. Females constituted 73.3% and 80% in SG and EG, respectively. Median time-to-gastric leak post LSG was six (range: 4-7) days in both groups. SG patients were surgically managed with primary repair of the gastric fistula and gastrojejunostomy in 13 patients or converting SG into Roux-en-Y gastric bypass in two patients, while EG patients were endoscopically managed with stitching, stenting, stenting and dilation, and clipping and dilation in 5, 4, 4 and 2 patients, respectively. Incidence of recurrent leak during 1st week was significantly higher in SG than EG (p < 0.001). No mortality reported in EG, while 2 patients died in SG (p = 0.48). CONCLUSION: Endoscopic intervention may offer a successful modality in managing post-LSG gastric leak and gastro-cutaneous fistula that do not respond to conservative measures in stable patients.