Complications of Mega Stent in Controlling the Leakage After Sleeve Gastrectomy

Complications of Mega Stent in Controlling the Leakage After

Sleeve Gastrectomy

Mohamed Ibrahim Hassan, MD; Mohamed Shaaban Khalifa, MD.

Department of General Surgery, Ain Shams University, Cairo, Egypt.

Background: Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of co-morbidities to that of laparoscopic gastric bypass. One of the dreaded complications after LSG is a gastric leak which may reach up to 5% and is most commonly occurring at the upper staple line near the gastro-esophageal junction. The use of flexible stents has been recently proposed as an alternative for the treatment of the esophago-gastric enteric leaks. We present our experience in the treatment of gastric leaks with coated self- expandable mega stents.

Patients and methods: This study included 15 patients who had gastric leaks at the gastro- esophageal (GE) junction after SG. Stents were placed endoscopically in 9 patients and the other 6 patients were managed laparscopically by drainage and closure of the leakage site with insertion of feeding jejuenostomy.

Results: Mega stent insertion had successfully controlled the leakage only in 2 patients; showed migration of the stent in 3 patients, failure of leakage control in another 2 patients and associated with bleeding in 1 case and marked esophageal narrowing in another case. Leaks were completely sealed in the 6 patients who had been managed with laparoscopic exploration and after feeding through the jejeunostomy tube for 2-3 weeks.

Conclusions: Mega stents are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery, however the complications related to the stent insertion and after removal together with the incidence of its ineffectiveness of leakage control make us reconsider the conventional drainage with the closure of the leakage site (if possible) with insertion of feeding jejeunostomy.

Key words: Gastric leaks, morbid obesity, bariatric surgery, sleeve gastrectomy, coated

stents.

Introduction:

Laparoscopic sleeve gastrectomy (LSG), also known as longitudinal or vertical gastrectomy, is a relatively new and effective surgical option for the management of morbid obesity. It was initially introduced in 1990 as an alternative to distal gastrectomy with the duodenal switch procedure to reduce the rate of complications.1

Sleeve  gastrectomy  was  first performed

laparoscopically by Ren and colleagues in

1999. At the time, LSG was considered a first-stage operation in high-risk patients before  biliopancreatic  diversion  or  Roux- en-Y gastric bypass.2–3

Laparoscopic sleeve gastrectomy was subsequently found to be effective as a single procedure for the treatment of morbid obesity. Although LSG functions as a restrictive procedure, it may also cause early satiety by removing  the  ghrelin-producing  portion  of the stomach.4

One of the dreaded complications after LSG is a gastric leak, most commonly occurring at the upper staple line near the gastro- esophageal  junction.5,6   This  complication if not identified and treated quickly and aggressively, may lead to abdominal sepsis, which might progress either to chronic gastric fistula or to multi-organ failure and patient

demise.7

The use of flexible stents has been recently proposed as an alternative for the treatment of enteric leaks after esophago-gastric surgery8 and also for leaks after bariatric surgery.9

Stent  placement  for  exclusion  of  the leak from the gastrointestinal tract is the endoscopic technique supported by the most substantial body of evidence. Stent placement allows the leak to heal while enteral nutrition is resumed, potentially accelerating recovery and avoiding the need for parenteral nutrition. Peritoneal    contamination    is    decreased, and improvement in abdominal pain may follow.10

Study design:

The aim of the current study is to present our  experience  on  the  self-expandable mega stents (TAEWOONGN Niti-S Mega Esophageal stent) for the management of gastric leakage after sleeve gastrectomy.

Patient and methods:

Between January 2011 and 2015, 390 patients benefitted from sleeve gastrectomy (SG) in 8B unit of Ain Shams university hospitals ,Elgolf International hospital and Dar Elhekma hospital .This study evaluated the outcome of 15 patients who developed leakage after laparscopic sleeve gastrectomy,

6 patients of our departments and the other

9 patients were referred to our university hospitals.

Mega Stent was inserted endoscopically on 9 patients. The other 6 patients were managed by laparoscopic exploration and drainage at the leakage site with or without closure of the leakage site with creation of feeding jejunostomy.

2 patients who had laparoscopic sleeve gastrectomy  showed  leakage  at  the  angle of His. One of them was a female patient

25 year old with BMI 41. The leakage was detected on the gastrograffin study on the 1st post operative day, while the other patient was a 36 year old male patient with BMI 46. He showed the signs of leakage 3 days later after discharge with normal gastrograffin study   postoperatively.   Ultrasound   guided

aspiration of localized collections was done before the insertion of the covered mega stent.

The gastrograffin study done on the second day after insertion of the stent had showed control of the leakage. The two patients started oral feeding on the second day and were discharged, both patients complained of intermitted mild to moderate epigastric pain, chest pain and reflux symptoms that were controlled by analgesic and PPI. The stent was kept for 7 weeks and was removed endosopically with smooth course.

3 of our patients had complained of stent migration down to the jejunum. Persistence of leakage was the main feature. 3-4 sessions were required for pulling up and repositioning the stent, which finally was effective in controlling the leak and was removed after 7 weeks.

Another 4 cases of leakage after sleeve gastrectomy were treated by mega stent insertion, however various complications had occurred.

A  25-year-old  male  with  BMI  37 kg/ m2, with type 2 diabetes mellitus, after laparoscopic sleeve gastrectomy, leakage at the GE junction was detected. Mega stent was inserted, the leakage was markedly controlled  but  minor  leakage  persisted  on the dye study. The patient was kept on total parental nutrition (TPN) with no oral feeding for 10 days but the dye study showed the persistence of that minor leakage.

TPN was extended to another 10 days with ultrasound guided aspiration of  a localized collection at the leakage site and the pelvis, the stent was removed after 8 weeks, with the persistence of minor leakage that was finally controlled after 7 days of stent removal.

Another 42-year-old woman with BMI 41. Four days after sleeve gastrectomy, a gastric leak at the angle of His was detected. Mega stent was inserted and the leakage control was confirmed by the dye study. The patient had started oral feeding and discharged, however the patient was readmitted 7 days later with signs of septicemia.

Pelvi- abdominal ultrasound was done showed a moderate pelvic collection. Midline exploration and drainage of the collection at

the site of leakage was done and the edges were approximated by 2-0 Vicryl sutures. Wide drains were inserted and feeding jejenostomy was inserted.

The patient was kept on the jejenostomy feeding for 3 weeks after which the leakage site was healed as confirmed by the dye study.

A 24-year-old woman with BMI 43 underwent a LSG. Two days after the operation, signs of leakage were detected as fever and tachycardia that was confirmed by the dye study.

Mega stent was inserted and the patient started oral feeding, however 2 days later, the patient complained of recurrent attacks of hematemesis that required transfusions of 2 unit of fresh blood as the hemoglobin level dropped to 7.5 gm/d. Upper GIT endoscopy was done, revealed multiple erosions on the duodenal wall by the lower edge of the stent so the stent was pulled up with epinephrine injection  at  the  erosion  site. The  bleeding was controlled, 7 weeks later the stent was removed with no signs of leakage.

A 38 -year-old woman with BMI 44 underwent a LSG. Two days later the signs of  leakage  and  the  dye  study  confirmed the prescience of leakage at the gastro- esophageal junction.

Mega stent was inserted and the patient started oral feeding, however she complained of severe epigastric pain hardly relieved by strong analgesics. The stent was removed 7 weeks later after the leakage site was healed. The  removal  was  done  with  difficulty  as the upper end of the stent had eroded the esophageal wall with marked narrowing of the esophagus not passable to the scope and she complained of marked dysphagia.

Esophageal dilation using savary dilators was done, however esophageal perforation had occurred, necessitated insertion of another esophageal stent and right sided intercostals tube for drainage.

The intercostal tube was kept for 10 days,

3 weeks later the stent was removed. The patient complained of moderate dysphagia that necessitated 3 session of esophageal dilation.

After      we      had      experienced      that

complications accompanied with the Mega stent insertion, we changed our policy toward any leakage after gastric sleeve through laparoscopic  exploration  and  drainage  of the  leakage  site  with  standard  creation  of the feeding jejenostomy. Such policy was done for 6 patients presented to us later with leakage after sleeve gastrectomy.

3 patients had showed the signs of leakage on the third day and were operated upon laparoscopically. It was not possible to approximate the edges of the leakage site because of the friability of the tissues, however good drainage and feeding jejenostomy was done.

The other 3 patients showed the signs of leakage on the second day postoperatively. We had approximated the edges with 2 stitches

2-0 vicryl with good drainage and the feeding jejenostomy was done laparscopically.

The patients were discharged to their home on the fourth day postoperatively and they were kept on feeding through the jejenostomy tube for 2 weeks. Healing of the leakage site was confirmed by the dye study, the tube was removed 1 week later for establishment of a well formed track.

The post operative period was smooth, however   one   of   our   explored   patients suffered from DVT and attacks of pulmonary embolism that was controlled by medical treatment.

Results:

We had used mega stent for nine patients to treat leaks after LSG. The mega stent was inserted endoscopically and it extended from the middle of the esophagus to the first part of the duodenum. In all cases the site of leakage was the gastro- esophageal junction. The patients had poor tolerance to the stent with mild to moderate, recurrent nausea and retrosternal discomfort.

However the leakage was not well controlled in 2 patients. One of them required urgent  midline  exploration  and  drainage of the pelvic collection with insertion of a jejeunostomy tube, while the other was kept on TPN for 7 days after the retrieval of the stent.

3 of our patients had complained of stent migration down to the jejunum. Persistence of leakage was the main feature. 3-4 sessions were required for pulling up and repositioning the stent.

Another patient complained of marked duodenal erosion at the lower end of the stent, presented by recurrent attacks of hematemeses which was controlled by endoscopic epinephrine.

The leakage site was controlled in 2 patients with no complications related to the stent other than epigastric chest pain with intermittent dysphagia.

We  adopted  the  policy  of  exploration and drainage of the leakage collections laparoscopically with standard creation of the feeding jejenostomy, such policy was done with 6 patients.

We could approximate the edges with 2-0 vicryl in 3 patients, however the tissues were friable on the other 3 patients, so we only ensured good drainage and insertion of the feeding tube.

The post operative period was smooth, however one patient had complained of DVT and pulmonary embolism.

Discussion:

Complication rates after primary bariatric operations are today within acceptable limits, although in the hands of the most experienced surgeons, both morbidity and mortality are inevitable.11

Gastric leak is one of the most serious and dreaded complication of LSG It occurs in up to 5% of patients following LSG.12

Leaks after bariatric operations are usually life threatening complications, traditionally treated with surgery, distal enteral feeding or total parenteral nutrition (TPN). The use of flexible stents has been recently proposed as an alternative for the treatment of enteric leaks after esophago-gastric surgery13 and also for leaks after bariatric surgery.14

We routinely test the incidence of possible leaks    intra-operatively    with    methylene blue, the 1st postoperative day with upper GI Gastrografin® studies. In our study, the detected cases of leakage were managed by

insertion of the endoscopic mega stent.

The placement of the stent can temporarily bypass the site of leakage and allow the patients  to  maintain  the  enteral  nutrition until complete closure of the leak. Stents must be tested with oral Gastrografin® after the implantation and also immediately after removal. Almost all authors have reported that the optimal time for removal of the stent is around 6-8 weeks.

Removal of the stent is not always easy. The  prostheses  are  silicone-coated,  but intense  adherence  of  the  stent  is  frequent, and mucosal laceration and bleeding are frequent after removal. Migration is another concern with the use of stents. The incidence of migration has been reported to be as high as one third of cases.15

We had maintained the stents for 7-8 weeks, in some cases leaks had persisted, so we kept the patients on TPN for another 1 week till the leakage site was healed.

However we experienced some complications related to the stent insertion as bleeding, esophageal stricture, stent migration and the persistence of the leakage site after the stent removal.

Himpens J et al, had mentioned that 29 patients who developed a leak at the angle of His. All patients were treated under general anesthesia by the placement of a covered stent. Stent treatment was immediately successful  in  19  patients,  as  documented by barium swallow performed the day after ablation of the stent. Ten patients, however, had positive barium swallow and/or methylen blue test and required insertion of a new stent for another six weeks.16

Renca c et al, had mentioned that fifteen patients presented with a leak after LSG, 6 of these patients required stenting as a secondary treatment. Although leaks from 3 patients resolved with stenting, the other 3 required re-stenting and 2 eventually underwent conversion to gastric bypass.17

Moszkowicz D, et al stated that the endoscopic stent was tried in nine patients but failed in 84.6 % of cases within 20 days. Seven patients necessitated total gastrectomy within  217  days  of  conservative  treatment

Figure (1): TAEWOONGN Niti-S Mega Esophageal stent - South Korea 415-873 T (28 mm diameters and 23 cm length).

Figure (1): Leakage at the angle of His.

Figure (3): Inserted mega stent.                             Figure (4): Persistence of leakage after the stent insertion.

Table (1)

failure. Endoscopic stents entail high failure rate, total gastrectomy is required in one third of the cases.18

Therefore, we suggest an exploratory laparoscopy    for    diagnosis    in    patients who  show  signs  of  leakage  in  the  early