Endoscopic management of sleeve leaks Mr Damien Loh Oesophagogastric and Bariatric Surgeon The Alfred
The clinical problem Incidence 0.1-7% Inpatient mortality 2-5% High morbidity Prolonged ICU and in-hospital stay Resource-intensive
Timing of presentation Immediate (1-3 days) Staple line failure Technical problem Early (5-30 days) Delayed/chronic (weeks to months) Fistula
Classification Type Findings Management 1a Phlegmon Conservative 1b Phlegmon with small amount of localised gas Conservative 2a Fluid and gas (localised) Percutaneous drainage +/- endoscopic therapy 2b 3a Fluid and extensive gas (multiple locules) Contained contrast leak (washes in and out of established cavity) Percutaneous or surgical drainage +/- endoscopic therapy Consider surgical drainage +/- endoscopic therapy 3b Free intra-peritoneal contrast leak Surgical drainage +/- endoscopic therapy 4 Chronic fistulisation Salvage surgery
Clinical assessment Unwell patient Surgical drainage Well patient Percutaneous drainage of collections Endoscopic assessment Endoscopic therapy as bridge to salvage surgery
Options for endoscopic therapy Internal drain Endoscopic vacuum therapy Stents Closure of fistula with clips/glue Surgical and radiological drains need to be well placed in collections to aid endoscopic therapy
Internal drains Endoscopic view of sleeve leak with two pigtail drains in situ
Outcomes of internal drain Author Nedelcu, et al 2015 Donatelli, et al 2014 Pequignot, et al 2012 Patients (N) Average number of procedures (N) Average healing time (days) Success rate (%) Complications 9 2.8 78 78 Drain migration (1) Additional surgery (1) 21 NR 55.5 95 Drain migration (1) 8 3 62 100 NR
Stents
Outcomes of stenting Author year Patients (N) Stent migration (%) Ulceration/ perforation (%) Stenting success (%) Mean duration (days) Bege et al. 2011 22 59 NR 100 86 0 Mortality (N) Pequignot et al. 2012 Sakran et al. 2012 Alazmi et al. 2014 Orive-Calzada et al. 2014 Christophorou et al. 2015 Southwell et al. 2016 Martin del Campo et al. - 2018 Klimczak et al. 2018 19 NR NR 94.7 28 n/a 11 NR NR 55 40 n/a 17 6 12 76 42 0 11 32 NR 73 NR 0 88 42.9 41.2 73.6 111 1 21 48 4.8 95 75 0 24 22 NR 66.7 61.5 1 14 46.1 7.1 76.9 34 2
Sleeve-specific stents
Sleeve-specific stents Author- year Patients (N) Stent type Stent migration (%) Oshiro et al. - 2010 Simon et al. 2013 Galloro et al. - 2014 Fishman et al. - 2015 Shehab et al. 2016 Wezenbeek et al. 2016 Klimczak et al. 2018 2 Hanaro stent (MI TECH) 9 Hanaro stent (MI TECH) 4 Megastent (Taewong) 26 Hanaro (5) Megastent (21) 13 Megastent (Taewong) 7 Hanaro stent (MI TECH) 14 Megastent (Taewong) Stenting success (%) Mean duration (days) 0 100 NR 0 11 78 141 0 0 100 56 0 27 65 NR 0 18 69 NR 2 85.7 (55% overall) 75 37.8 0 46.1 77 34 2 Mortality (N)
Principles of vacuum-assisted closure (VAC) therapy
Endoscopic vacuum therapy First reported in 2008 1 Anastomotic leaks after anterior resection Definitive healing achieved in 28 of 29 patients Initial case reports for oesophagogastric anastomotic leaks in 2008 2 2 patients failure of surgical reintervention or stent Closure achieved after median of 5 endoscopic interventions and 15 days 1. Weidenhagen et al. Surg Endosc, 2008 Aug; 22(8): 1818-1825. 2. Wedemeyer et al. Gastrointest Endosc, 2008 Apr; 67(4): 708-711.
Endoscopic vacuum therapy technique
Outcomes of E-VAC therapy Leeds SG, Burdick JS 9 patients 55% (5/9) prior failure of stent therapy 100% resolution of leak after average 50 days of E-Vac therapy Average 10.3 procedures per patient One death 89% successful rescue therapy
The Alfred experience 7 sleeve gastrectomy leaks Average 10 procedures per patient Mean duration of E-Vac therapy 39 days Resolution of leak in 4 patients (57%) Three patients underwent completion gastrectomy with Roux-en- Y reconstruction No mortality
Effects of E-VAC therapy Phase 1 Phase 2 Phase 3 Phase 1 (1-2 weeks): Reduction in external drain output Phase 2 (2-3 weeks): Resolution of inflammatory markers Phase 3 (3-4 weeks): Reduction in EndoVAC output and closure of cavity
Over-the-scope clips Adjunct to stenting Closure of fistula subsequent to previous techniques
Factors influencing healing Successful Simple cavity Smaller cavity (generally <8cm) Early injury Unsuccessful Complex, loculated cavity Large cavity Chronic, fibrosed cavity Significant contamination
Unwell Yes No Surgical drainage Endoscopic assessment Leak orifice < 10mm Leak orifice > 10mm Internal pigtail drain Stent Endoscopic vacuum therapy
Take home messages Sleeve gastrectomy leaks have high morbidity and can be difficult to manage Multidisciplinary team approach is useful Surgical and radiological drains need to be well-placed Endoscopic therapy useful for early leaks and as adjunct to surgery
References 1. Nedelcu M, et al. Outcomes of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. Obes Surg (2015); 25: 559-563. 2. Donatelli G, et al. Endoscopic internal drainage with enteral nutrition (EDEN) for treatment of leaks following sleeve gastrectomy. Obes Surg (2014); 24: 1400-1407. 3. Pequignot A, et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy. Obes Surg (2012); 22: 712-720. 4. Sakran N, et al. Gastric leaks after sleeve gastrectomy: a multicentre experience with 2,834 patients. Surg Endosc (2013); 27: 240-245. 5. Alazmi W, et al. Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature. Surg Endosc (2014); 28: 3425-3428. 6. Orive-Calzada A, et al. Closure of benign leaks, perforations, and fistulas with temporary placement of fully covered metal stents: a retrospective analysis. Surg Laparosc Endosc Percutan Tech (2014); 24(6): 528-536. 7. Christophorou D, et al. Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicentre retrospective study. Endoscopy (2015); 47: 988-996. 8. Southwell T, et al. Endoscopic therapy for treatment of staple line leaks post-laparoscopic sleeve gastrectomy: experience from a large bariatric surgery centre in New Zealand. Obes Surg (2016); 26: 1155-1162. 9. Martin del Campo SE, et al. Endoscopic stent placement for treatment of sleeve gastrectomy leak: a single institution experience with fully covered stents. Surg Obes Relat Dis (2018); 14: 453-461. 10. Klimcazk T, et al. Endoscopic treatment of leaks after laparoscopic sleeve gastrectomy using MEGA oesophageal covered stents. Surg Endosc (2018); 32: 2038-2045. 11. Oshiro T, et al. Successful management of refractory staple line leakage at the oesophagogastric junction after a sleeve gastrectomy using the HANAROSTENT. Obes Surg (2010); 20: 530-534.
References 12. Simon F, et al. Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time. Obes Surg (2013); 23: 687-692. 13. Galloro G, et al. A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series. Surg Obes Relat Dis (2014); 10: 607-612. 14. Fishman S, et al. Use of sleeve-customised self-expandable metal stents for the treatment of staple-line leakage after laparoscopic sleeve gastrectomy. Gastrointest Endosc (2015); 81(5): 1291-1294. 15. Shehab HM, et al. An endoscopic strategy combining mega stents and over-the-scope clips for the management of post-bariatric surgery leaks and fistulas. Obes Surg (2016); 26: 941-948. 16. van Wezenbeek MR, et al. A specifically designed stent for anastomotic leaks after bariatric surgery: experiences in a tertiary referral hospital. Obes Surg (2016); 26: 1875-1880. 17. Weidenhagen R, et al. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc (2008); 22(8): 1818-1825. 18. Wedemeyer J, et al. Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks. Gastrointest Endosc (2008); 67(4): 708-711. 19. Kuehn F, et al. Endoscopic vacuum therapy for various defects of the upper gastrointestinal tract. Surg Endosc (2017); 31: 3449-3458. 20. Leeds SG, Burdick JS. Management of gastric leaks after sleeve gastrectomy with endoluminal vacuum (E-Vac) therapy. Surg Obes Relat Dis, (2016); 12(7): 1278-1285. 21. Ooi G, et al. Indications and efficacy of endoscopic vacuum-assisted closure therapy for upper gastrointestinal perforations. ANZ J Surg (2018); 88(4): E257-E263.