Endoscopic Management of Postbariatric Fistulae and Leaks

Abstract

The number of bariatric procedures performed annually is increasing along with the number of complications. Gastrointestinal leak after bariatric surgery generally portends high morbidity and mortality, and its management depends on clinical and radiographic presentation. A leak is defined as an enteric defect with extravasation of luminal contents. Fistulae are abnormal connections between two epithelialized surfaces, are usually chronic, and may develop from long-standing leaks. Endoscopic therapies may offer an attenuated risk profile compared with surgical intervention and play a growing role in the management of postbariatric complications. Leak resolution may require multiple endoscopic sessions and modalities (e.g., stents, adhesives, plugs, clips, suturing, and VAC-assisted closure); therefore, it is critical to have appropriate follow-up and surveillance after therapeutic endoscopic intervention. This review discusses endoscopic leak and fistula management through endoscopic procedures, addressing indications and candidates for procedure, contraindications, recipient evaluation, and aspects of procedure, including proper timing, equipment, and types. Figures show Roux-en-Y gastric bypass, sleeve gastrectomy, management options for leaks after bariatric surgery, a diagnostic algorithm for leaks, upper gastrointestinal series performed with Gastrografin, and computed tomographic scans that demonstrate extraluminal air extending along the diaphragmatic surface of the spleen and a perisplenic gas and fluid-filled collection on the lateral margin. Tables list complications that follow bariatric surgery; an excerpt from the 2008 American Society for Gastrointestinal Endoscopy Guidelines; recommended equipment for endoscopic defect management; classification system based on duration after bariatric surgery; classification and approach to management based on clinical presentation and radiographic findings; summary of recommendations for pre-endoscopy, index endoscopy, therapeutic endoscopy, and posttherapeutic endoscopy; and early and late complications of stent placement. This review contains 7 highly rendered figures, 7 tables, and 104 references.