Temporary Use of a Fully Covered Self-Expandable Metal Stent for Treatment of Bariatric Surgery Complications

Abstract

Purpose: Fully covered self expandable metal stents (FCSEMS) have been used in selected cases to manage post-bariatric surgical complications, though the data are limited. Such complications include gastric body strictures (sleeve gastrectomy), anastomotic strictures (Roux-en-Y gastric bypass), and fistulae. Aim: To report the outcome following FCSEMS placement for management of post-bariatric surgery complications using one type of FCSEMS. Methods: The medical records of all patients having undergone placement of one type of FCSEMS (Alimaxx-E, Merit Medical Systems, Inc.) from 1/1/2005 to 5/17/2010 were reviewed after IRB consent was obtained. 165 patients were initially identified and 15 of these had a FCSEMS placed exclusively to treat a complication resulting from bariatric surgery or surgical revision of a prior bariatric surgery. Data were abstracted for patient demographics, indications for stent placement, technical success, clinical outcomes, and stent related complications. Results: The 15 patients (mean age 48 years, 10 female) included 11 Rouxen-Y gastric bypass, 3 duodenal switch, and one sleeve gastrectomy patient. Indications for FCSEMS placement were stricture (9 patients), fistula (3 patients), and both stricture and fistula (3 patients). A total of 20 attempted FCSEMS placements occurred at a mean time of 514 days after surgery (range 14-1640 days). Technical success with placement was achieved in 19/20 attempts. Mean stent dwell time was 63 days. Endoscopic resolution of stricture was seen in 9/12 (75%) of stricture patients at time of stent removal, however, 7 of these patients developed recurrent strictures. Improvement in fistula was seen in 2/6 patients and did not required re-intervention up to 12 months after stent removal. Complications included 6 stent migrations, 2 of which lodged in the distal small bowel; one of these also caused a perforation and both required surgical removal/repair. A third stent migrated into the colon and was endoscopically removed. All other stents were completely removed by upper endoscopy; stent fragmentation during removal occurred in one case and was without sequela. Ultimately, 8/16 patients underwent surgery due to stricture recurrence or persistent fistulae despite FCSEMS placement. Conclusion: 1) Temporary placement of FCSEMS alone for management of post-bariatric surgery complications appears to have limited efficacy, with poor to moderate long term results. 2) Stent migration with subsequent small bowel obstruction or perforation was observed, and 50% of all patients required surgery for ultimate correction of their primary problem. 3) Adjuvant therapy such as fibrin glue could potentially improve outcome of fistula closure. Disclosure: Dr Johan C. Bakken: No financial disclosures Dr Wong Kee Song: No financial disclosures Dr Todd Baron - Paid Speaker: Alveolus, Inc.