Philadelphia—The number of people undergoing bariatric surgery continues to climb, and although expertise and refinement in the procedures may lead to less postoperative morbidity, the overall population of patients with complications is not small.
Once the realm of surgery, endoscopy is becoming a first-line approach to managing these complications and many, such as leaks and fistulas, can be repaired using skills common to all physicians trained in interventional gastroenterology.
“Most of us would agree that endoscopic management is reasonable to consider in early postoperative care; we want to avoid reoperating on these patients if possible,” said Steven Edmundowicz, MD, professor of medicine and chief of endoscopy at Washington University Hospital, in St. Louis. Dr. Edmundowicz discussed the role of endoscopy in post-bariatric surgery complications at the 2014 annual meeting of the American College of Gastroenterology.
Leaks occur in as many as about 8% of bariatric surgery patients, Dr. Edmundowicz said, and present fairly early on—within one to two days for those caused by a mechanical disruption, five to seven days for those caused by tissue ischemia. Like any other approach in this situation, endoscopic intervention has a failure rate, “but it can be very effective and patients can recover rapidly and resume oral nutrition,” he said.
Management of leaks begins with detection, usually with computed tomography (CT) imaging and oral contrast. “You can certainly perform an upper GI [gastrointestinal] contrast study or CT scan and identify large leaks. Smaller leaks are subtle and can be found with endoscopy, sometimes with the help of a bubble test,” Dr. Edmundowicz said.
Closure is obtained using standard or over-the-scope clips, as well as suturing and stents—although no stent is explicitly labeled for this use. “We use fully covered esophageal stents in an off-label indication,” Dr. Edmundowicz said. Stent migration is an issue, but using multiple stents, endoscopic suturing or over-the-scope clips to fix the stent in place can mitigate this problem.
Through-the-scope clips can be used to manage smaller leaks, but these should be limited to mucosal and submucosal closure, Dr. Edmundowicz said. “For larger defects, over-the-scope clips and endoscopic suturing are much more useful; they allow you to close the defect with a submucosal or muscular propria layer closure,” Dr. Edmundowicz said.
Endoscopic suturing also has become an option for repairing lesions in the proximal GI tract, allowing the endoscopist to close more significant defects. “There are significant challenges in terms of device size, field of view and maneuverability,” Dr. Edmundowicz said. “But we can usually visualize lesions in the gastric pouch and esophagus quite well. There has been very positive anecdotal and series experience, and many of us are gaining experience closing defects with these devices.”
To achieve the best outcomes as rapidly as possible, Dr. Edmundowicz recommended a combination of closure and stenting. “If you’re going to make the effort to treat a patient with an acute postoperative injury, you’ll probably want to close [the defect] as well as stent it,” he said.
Another problem endoscopists are increasingly encountering is the erosion of the laparoscopic band. “There is an epidemic of this complication because a great number of bands have been placed and a significant number of them will eventually erode into the stomach,” Dr. Edmundowicz said. “Fortunately, the bands tend to be well encapsulated, so there is usually limited or no danger of creating a perforation when they erode and while removing them.”
One technique for doing so involves passing a 0.35-inch guidewire endoscopically through the band, grasping it with a snare and pulling the entire wire out of the patient’s mouth, thereby creating a loop around the band.
“Once that’s accomplished, we can position the wire and use the handle and sheath from a salvage mechanical lithotripter system to engage the wire and use it as a cutting device to break through the band,” Dr. Edmundowicz said.
After the band is cut, the endoscopist uses the snare and grasping forceps to pull the band into the stomach, where it can be grasped and extracted from the patient, Dr. Edmundowicz explained. The port will need to be removed by a surgeon.
Endoscopists also may play a role in anastomotic reduction in situations in which patients who have undergone Roux-en-Y gastric bypass experience weight gain resulting from dilation of the gastrojejunostomy. “With dilation, the restrictive component of the operation is defeated,” Dr. Edmundowicz said. “If we can narrow the anastomosis, we can usually get some improvement in these patients.”
Chemically narrowing the anastomosis by applying the sclerosing agent morrhuate sodium has been effective (Gastrointest Endosc 2007;66:240-245), and endoscopic techniques and devices in this area have advanced. One large multicenter trial investigating narrowing of the anastomosis using an endosuturing device found significant improvement in weight loss after the procedure.
“The clinical improvement we saw with our patients in this trial was not quite as dramatic, but I think with the newer devices available, we should be able to get more robust closure of the anastomosis,” Dr. Edmundowicz said.
Some techniques used in the management of complications after bariatric surgery, such as endoscopic suturing, are quite advanced and would require special training. “These are things not everyone is doing and not everyone will be doing in the future,” said David Greenwald, MD, GI fellowship program director at Montefiore Medical Center, in New York City.
But the evolution of devices may make it easier for endoscopists who want to extend their armamentarium of services. “The devices keep getting better and better,” Dr. Greenwald said. “With each passing year endoscopic suturing devices, for example, seem to be easier to use and to require fewer special skills, more in the realm of something a generally trained endoscopist would know how to do.”
Even so, many complications can be managed using skills familiar to most endoscopists. “Identifying and treating an ulcer is a common skill, or dealing with strictures that occur at the site of anastomosis—all gastroenterologists are trained in the dilation used to treat these,” Dr. Greenwald explained.
“It’s a bit more complicated because you have to understand the altered anatomy and what the surgeon has done, but it’s clearly within the realm of all gastroenterologists.”