AGA Clinical Practice Update on Evaluation and Management of Early Complications After Bariatric/Metabolic Surgery: Expert Review

Abstract

Endoscopic techniques are paramount in the identification and management of complications after surgery, though collaboration with other specialties is obligatory. Unfortunately, the evaluation and treatment algorithms are not standardized and there is a paucity of high-quality prospective studies to provide clarity regarding the best approach. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery. The best practice advice outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. BEST PRACTICE ADVICE 1: Clinicians performing endoscopic approaches to treat early major postoperative complications should do so in a multidisciplinary manner with interventional radiology and bariatric/metabolic surgery co-managing the patient. Daily communication is advised. BEST PRACTICE ADVICE 2: Clinicians embarking on incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a comprehensive knowledge of the indications, contraindications, risks, benefits, and outcomes of each of the endoscopic treatment techniques. They should also have knowledge of the risks and benefits of alternative methods such as surgical and interventional radiological based approaches. BEST PRACTICE ADVICE 3: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have expertise in interventional endoscopy techniques, including but not limited to: using concomitant fluoroscopy, stent deployment and retrieval, managing stenosis, and managing percutaneous drains. BEST PRACTICE ADVICE 4: Clinicians should screen all patients undergoing endoscopic management of bariatric/metabolicsurgical complications and dietary intolerance for comorbid medical (nutrient deficiencies, infection, pulmonary embolism) and psychological (depression, anxiety) conditions. BEST PRACTICE ADVICE 5: Endoscopic approaches to managing complications of bariatric/metabolic surgery may be considered for patients in the immediate, early and late postoperative periods depending on hemodynamic stability. BEST PRACTICE ADVICE 6: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a detailed understanding of the pathophysiologic mechanisms initiating and perpetuating conditions such as staple-line leaks. This will allow for a prompt diagnosis and appropriate therapy to be targeted not only at the area of interest, but also any concomitant downstream stenosis. BEST PRACTICE ADVICE 7: Clinicians should recognize that the goal for endoscopic management of staple-line leaks are often not necessarily initial closure of the leak site, but rather techniques to promote drainage of material from the perigastric collection into the gastric lumen such that the leak site closes by secondary intention.