Treatment of gastric leaks after sleeve gastrectomy

It is with great interest that we read the article entitled “Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study” [1], concerning the endoscopic management of gastric leakage after laparoscopic sleeve gastrectomy (LSG).

Christophorou et al. are to be congratulated on the quality of their work. This is the first study of a relatively large patient population (n = 110) to have highlighted a number of factors associated with a shortened time to resolution of gastric leakage after LSG: the absence of a history of gastric banding; small size of fistula (measuring less than 1 cm in diameter); a short time interval between LSG and the onset of gastric leakage (≤ 3 days); and a short time interval between diagnosis and the first endoscopy. Furthermore, the study’s results emphasize that long, complicated endoscopic treatment is associated with a low gastric leakage healing rate and therefore a requirement for revisional surgery.

However, the report of Christophorou et al. suggests that endoscopy is the only possible treatment for gastric leakage and fails to mention the standardized perioperative management of patients with gastric leakage (such as treatment with proton pump inhibitors, somatostatin, or antifungal agents). Furthermore, the type of early reoperation (although not standardized) is hardly mentioned in their report – despite the fact that this may have a significant impact on the outcome of endoscopic treatment. For example, suturing of the fistula is feasible in more than 30 % of cases of early-onset gastric leakage and may allow full healing or at least reduce the size of the orifice [2].

We agree with Christophorou et al. that stent placement is associated with a high complication rate; this explains why in recent series the use of internal drainage with double-pigtail catheters (DPCs) has been preferred, and why the use of stents is increasingly being abandoned [3] [4]. Furthermore, some (but not all) studies of stent placement for gastric leakage have reported poor safety results, with a high incidence of gastroesophageal reflux and pain requiring stent removal (in some patients). In our experience and that of many other centers [5], stents are still very valuable in some indications. Some cases of post-LSG gastric leakage are associated with gastric stenosis [6] and others feature a large fistulous orifice (greater than 2 cm in diameter). The use of DPCs may then be associated with failure due to intragastric overpressure (in cases of stenosis) or DPC migration (in cases with a large orifice, even when two DPCs are used). In this context, a stent can be used alone [6] or in combination with a trans-stent DPC [7].

Our experience with over-the-scope clips (OTSCs) differs from that of Christophorou et al. We observed a high failure rate, requiring the use of DPCs as an alternative endoscopic procedure. In contrast to the new management algorithm from Christophorou et al., we consider that OTSCs cannot be used for gastric leakage with a large fistulous orifice or as a first-line endoscopic treatment. In our experience, the presence of inflammation means that the edge of the fistula is too fragile for lasting closure with first-line use of OTSCs (even for orifices measuring less than 1 cm in diameter). Furthermore, the use of OTSCs after DPC placement is of little value, since the presence of pseudodiverticula facilitates healing, does not have a harmful impact on the time to refeeding or the recurrence of gastric leakage, and thus does not require any further treatment [3]. We consider that the management algorithm developed by Christophorou et al. is too simple.

Lastly, the treatment of gastric leakage (based on drainage, whether surgical, endoscopic, or radiological) is difficult and requires a multidisciplinary approach involving surgeons, endoscopists, and radiologists. Endoscopy is an important treatment option but must be adapted to suit the particular features of the gastric leakage. In the absence of an improvement, revisional surgery should not be delayed.

• References

• 1 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 Epub 2015 Jun 25
• 2 Rebibo L, Bartoli E, Dhahri A et al. Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation. Surg Obes Relat Dis 2016; 12: 84-93 (Epub 2015 Apr 24)
• 3 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
• 4 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
• 5 Manos T, Nedelcu M, Noel P et al. Pigtails internal drainage for 2-cm gastric leak after sleeve gastrectomy prolongs healing. Obes Surg 2015; 25: 1261-1262
• 6 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
• 7 Rebibo L, Fumery M, Hakim S et al. Combined stents for the treatment of large gastric fistulas or stenosis after sleeve gastrectomy. Endoscopy 2015; 47: E59-60 (Epub 2015 Feb 17)