Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy

results from a large multicenter U.S. cohort

Zachary L. Smith, Kenneth H. Park, Ernesto M. Llano, Kianoush Donboli, Lea Fayad, Samuel Han, Lorna Kang, Robert T. Simril, Riddhi Patel, Thomas Hollander, Melinda C. Rogers, B. Joseph Elmunzer, Uzma D. Siddiqui, A. Aziz Aadam, Daniel K. Mullady, Gabriel D. Lang, Koushik K. Das, Laith H. Jamil, Simon K. Lo, Srinivas Gaddam & 6 others Christopher G. Chapman, Rajesh N. Keswani, Sachin Wani, Gregory A. Cote, Vivek Kumbhari, Vladimir M. Kushnir

Research output: Contribution to journalArticle

Abstract

Background: Sleeve gastrectomy is the most commonly performed bariatric surgery in the United States. Leaks after sleeve gastrectomy (SGL) occur in 1% to 3% of patients. Endoscopic therapies are increasingly used for treatment of SGLs, but few data exist on their outcomes. Objectives: The aim of this study was to assess technical success, leak resolution, and reoperation rates of patients undergoing endoscopic therapy for repair SGLs. Setting: Eight high-volume academic endoscopy centers. Methods: Patients undergoing endoscopic therapy for SGLs from 2007 to 2017 were identified. Patients were excluded if the index endoscopic therapy for SGL was performed elsewhere or if no follow-up data were available. Leaks were classified as acute (≤7 d of SG), early (1–6 wk), late (7–12 wk), and chronic (>12 wk). Leak resolution was defined as lack of extraluminal air, extravasation on oral contrast radiography, cross-sectional imaging, or resolution of percutaneous drain output. Demographic and procedural data were recorded as rates of additional therapy, adverse events, and surgical revision. Results: A total of 85 patients met criteria for analysis (70 women, age 42.6 ± 10.8 yr). A total of 295 endoscopic sessions (median 3, range 1–14) were performed across the cohort. SGLs resolved after index endoscopic therapy in 43 (50.1%) patients. The primary outcome of endoscopic resolution of SGL was observed in 62 patients (72.9%). There were 34 (11.5%) PRAE (the majority occurring with self-expandable metal stents), all but 1 of which were managed endoscopically. Surgical revision was required in 23 (21.7%) patients. On univariate analyses independent variables associated with the need for surgical revision included both acute and chronic SGLs (P = .028), loculated subphrenic collections/abscesses (P = .03), and intraabdominal sepsis (P = .03). On multivariable logistic regression using statistically significant predictors from the univariate analyses, acute SGLs were significantly associated with a need for surgical revision (odds ratio 4.8, 95% confidence interval 1.2–18.9, P = .025). Conclusion: Endoscopic therapy for SGLs is associated with good clinical success, avoiding the need for surgical revision in 73% of patients, with an acceptable adverse event profile. Patients with acute or chronic SGLs and those with loculated abscesses or intraabdominal sepsis are more likely to undergo surgical revision. Endoscopic therapy is an appropriate first-line modality for the management of SGLs, especially those not classified as acute or chronic.

Original languageEnglish (US)
JournalSurgery for Obesity and Related Diseases
DOIs
StatePublished - Jan 1 2019

Fingerprint

Gastrectomy
Fistula
Reoperation
Therapeutics
Sepsis
Subphrenic Abscess
Bariatric Surgery
Radiography
Abscess
Endoscopy
Logistic Models
Odds Ratio
Air
Demography
Confidence Intervals

Keywords

  • Endoscopy
  • Leak
  • Sleeve gastrectomy

ASJC Scopus subject areas

  • Surgery

Cite this

Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy : results from a large multicenter U.S. cohort. / Smith, Zachary L.; Park, Kenneth H.; Llano, Ernesto M.; Donboli, Kianoush; Fayad, Lea; Han, Samuel; Kang, Lorna; Simril, Robert T.; Patel, Riddhi; Hollander, Thomas; Rogers, Melinda C.; Elmunzer, B. Joseph; Siddiqui, Uzma D.; Aadam, A. Aziz; Mullady, Daniel K.; Lang, Gabriel D.; Das, Koushik K.; Jamil, Laith H.; Lo, Simon K.; Gaddam, Srinivas; Chapman, Christopher G.; Keswani, Rajesh N.; Wani, Sachin; Cote, Gregory A.; Kumbhari, Vivek; Kushnir, Vladimir M.

In: Surgery for Obesity and Related Diseases, 01.01.2019.

Research output: Contribution to journalArticle

Smith, ZL, Park, KH, Llano, EM, Donboli, K, Fayad, L, Han, S, Kang, L, Simril, RT, Patel, R, Hollander, T, Rogers, MC, Elmunzer, BJ, Siddiqui, UD, Aadam, AA, Mullady, DK, Lang, GD, Das, KK, Jamil, LH, Lo, SK, Gaddam, S, Chapman, CG, Keswani, RN, Wani, S, Cote, GA, Kumbhari, V & Kushnir, VM 2019, 'Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort', Surgery for Obesity and Related Diseases. https://doi.org/10.1016/j.soard.2019.04.009
Smith, Zachary L. ; Park, Kenneth H. ; Llano, Ernesto M. ; Donboli, Kianoush ; Fayad, Lea ; Han, Samuel ; Kang, Lorna ; Simril, Robert T. ; Patel, Riddhi ; Hollander, Thomas ; Rogers, Melinda C. ; Elmunzer, B. Joseph ; Siddiqui, Uzma D. ; Aadam, A. Aziz ; Mullady, Daniel K. ; Lang, Gabriel D. ; Das, Koushik K. ; Jamil, Laith H. ; Lo, Simon K. ; Gaddam, Srinivas ; Chapman, Christopher G. ; Keswani, Rajesh N. ; Wani, Sachin ; Cote, Gregory A. ; Kumbhari, Vivek ; Kushnir, Vladimir M. / Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy : results from a large multicenter U.S. cohort. In: Surgery for Obesity and Related Diseases. 2019.
@article{249ec0f1841d45b1a4e5f6c711b066aa,
title = "Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort",
abstract = "Background: Sleeve gastrectomy is the most commonly performed bariatric surgery in the United States. Leaks after sleeve gastrectomy (SGL) occur in 1{\%} to 3{\%} of patients. Endoscopic therapies are increasingly used for treatment of SGLs, but few data exist on their outcomes. Objectives: The aim of this study was to assess technical success, leak resolution, and reoperation rates of patients undergoing endoscopic therapy for repair SGLs. Setting: Eight high-volume academic endoscopy centers. Methods: Patients undergoing endoscopic therapy for SGLs from 2007 to 2017 were identified. Patients were excluded if the index endoscopic therapy for SGL was performed elsewhere or if no follow-up data were available. Leaks were classified as acute (≤7 d of SG), early (1–6 wk), late (7–12 wk), and chronic (>12 wk). Leak resolution was defined as lack of extraluminal air, extravasation on oral contrast radiography, cross-sectional imaging, or resolution of percutaneous drain output. Demographic and procedural data were recorded as rates of additional therapy, adverse events, and surgical revision. Results: A total of 85 patients met criteria for analysis (70 women, age 42.6 ± 10.8 yr). A total of 295 endoscopic sessions (median 3, range 1–14) were performed across the cohort. SGLs resolved after index endoscopic therapy in 43 (50.1{\%}) patients. The primary outcome of endoscopic resolution of SGL was observed in 62 patients (72.9{\%}). There were 34 (11.5{\%}) PRAE (the majority occurring with self-expandable metal stents), all but 1 of which were managed endoscopically. Surgical revision was required in 23 (21.7{\%}) patients. On univariate analyses independent variables associated with the need for surgical revision included both acute and chronic SGLs (P = .028), loculated subphrenic collections/abscesses (P = .03), and intraabdominal sepsis (P = .03). On multivariable logistic regression using statistically significant predictors from the univariate analyses, acute SGLs were significantly associated with a need for surgical revision (odds ratio 4.8, 95{\%} confidence interval 1.2–18.9, P = .025). Conclusion: Endoscopic therapy for SGLs is associated with good clinical success, avoiding the need for surgical revision in 73{\%} of patients, with an acceptable adverse event profile. Patients with acute or chronic SGLs and those with loculated abscesses or intraabdominal sepsis are more likely to undergo surgical revision. Endoscopic therapy is an appropriate first-line modality for the management of SGLs, especially those not classified as acute or chronic.",
keywords = "Endoscopy, Leak, Sleeve gastrectomy",
author = "Smith, {Zachary L.} and Park, {Kenneth H.} and Llano, {Ernesto M.} and Kianoush Donboli and Lea Fayad and Samuel Han and Lorna Kang and Simril, {Robert T.} and Riddhi Patel and Thomas Hollander and Rogers, {Melinda C.} and Elmunzer, {B. Joseph} and Siddiqui, {Uzma D.} and Aadam, {A. Aziz} and Mullady, {Daniel K.} and Lang, {Gabriel D.} and Das, {Koushik K.} and Jamil, {Laith H.} and Lo, {Simon K.} and Srinivas Gaddam and Chapman, {Christopher G.} and Keswani, {Rajesh N.} and Sachin Wani and Cote, {Gregory A.} and Vivek Kumbhari and Kushnir, {Vladimir M.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.soard.2019.04.009",
language = "English (US)",
journal = "Surgery for Obesity and Related Diseases",
issn = "1550-7289",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy

T2 - results from a large multicenter U.S. cohort

AU - Smith, Zachary L.

AU - Park, Kenneth H.

AU - Llano, Ernesto M.

AU - Donboli, Kianoush

AU - Fayad, Lea

AU - Han, Samuel

AU - Kang, Lorna

AU - Simril, Robert T.

AU - Patel, Riddhi

AU - Hollander, Thomas

AU - Rogers, Melinda C.

AU - Elmunzer, B. Joseph

AU - Siddiqui, Uzma D.

AU - Aadam, A. Aziz

AU - Mullady, Daniel K.

AU - Lang, Gabriel D.

AU - Das, Koushik K.

AU - Jamil, Laith H.

AU - Lo, Simon K.

AU - Gaddam, Srinivas

AU - Chapman, Christopher G.

AU - Keswani, Rajesh N.

AU - Wani, Sachin

AU - Cote, Gregory A.

AU - Kumbhari, Vivek

AU - Kushnir, Vladimir M.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: Sleeve gastrectomy is the most commonly performed bariatric surgery in the United States. Leaks after sleeve gastrectomy (SGL) occur in 1% to 3% of patients. Endoscopic therapies are increasingly used for treatment of SGLs, but few data exist on their outcomes. Objectives: The aim of this study was to assess technical success, leak resolution, and reoperation rates of patients undergoing endoscopic therapy for repair SGLs. Setting: Eight high-volume academic endoscopy centers. Methods: Patients undergoing endoscopic therapy for SGLs from 2007 to 2017 were identified. Patients were excluded if the index endoscopic therapy for SGL was performed elsewhere or if no follow-up data were available. Leaks were classified as acute (≤7 d of SG), early (1–6 wk), late (7–12 wk), and chronic (>12 wk). Leak resolution was defined as lack of extraluminal air, extravasation on oral contrast radiography, cross-sectional imaging, or resolution of percutaneous drain output. Demographic and procedural data were recorded as rates of additional therapy, adverse events, and surgical revision. Results: A total of 85 patients met criteria for analysis (70 women, age 42.6 ± 10.8 yr). A total of 295 endoscopic sessions (median 3, range 1–14) were performed across the cohort. SGLs resolved after index endoscopic therapy in 43 (50.1%) patients. The primary outcome of endoscopic resolution of SGL was observed in 62 patients (72.9%). There were 34 (11.5%) PRAE (the majority occurring with self-expandable metal stents), all but 1 of which were managed endoscopically. Surgical revision was required in 23 (21.7%) patients. On univariate analyses independent variables associated with the need for surgical revision included both acute and chronic SGLs (P = .028), loculated subphrenic collections/abscesses (P = .03), and intraabdominal sepsis (P = .03). On multivariable logistic regression using statistically significant predictors from the univariate analyses, acute SGLs were significantly associated with a need for surgical revision (odds ratio 4.8, 95% confidence interval 1.2–18.9, P = .025). Conclusion: Endoscopic therapy for SGLs is associated with good clinical success, avoiding the need for surgical revision in 73% of patients, with an acceptable adverse event profile. Patients with acute or chronic SGLs and those with loculated abscesses or intraabdominal sepsis are more likely to undergo surgical revision. Endoscopic therapy is an appropriate first-line modality for the management of SGLs, especially those not classified as acute or chronic.

AB - Background: Sleeve gastrectomy is the most commonly performed bariatric surgery in the United States. Leaks after sleeve gastrectomy (SGL) occur in 1% to 3% of patients. Endoscopic therapies are increasingly used for treatment of SGLs, but few data exist on their outcomes. Objectives: The aim of this study was to assess technical success, leak resolution, and reoperation rates of patients undergoing endoscopic therapy for repair SGLs. Setting: Eight high-volume academic endoscopy centers. Methods: Patients undergoing endoscopic therapy for SGLs from 2007 to 2017 were identified. Patients were excluded if the index endoscopic therapy for SGL was performed elsewhere or if no follow-up data were available. Leaks were classified as acute (≤7 d of SG), early (1–6 wk), late (7–12 wk), and chronic (>12 wk). Leak resolution was defined as lack of extraluminal air, extravasation on oral contrast radiography, cross-sectional imaging, or resolution of percutaneous drain output. Demographic and procedural data were recorded as rates of additional therapy, adverse events, and surgical revision. Results: A total of 85 patients met criteria for analysis (70 women, age 42.6 ± 10.8 yr). A total of 295 endoscopic sessions (median 3, range 1–14) were performed across the cohort. SGLs resolved after index endoscopic therapy in 43 (50.1%) patients. The primary outcome of endoscopic resolution of SGL was observed in 62 patients (72.9%). There were 34 (11.5%) PRAE (the majority occurring with self-expandable metal stents), all but 1 of which were managed endoscopically. Surgical revision was required in 23 (21.7%) patients. On univariate analyses independent variables associated with the need for surgical revision included both acute and chronic SGLs (P = .028), loculated subphrenic collections/abscesses (P = .03), and intraabdominal sepsis (P = .03). On multivariable logistic regression using statistically significant predictors from the univariate analyses, acute SGLs were significantly associated with a need for surgical revision (odds ratio 4.8, 95% confidence interval 1.2–18.9, P = .025). Conclusion: Endoscopic therapy for SGLs is associated with good clinical success, avoiding the need for surgical revision in 73% of patients, with an acceptable adverse event profile. Patients with acute or chronic SGLs and those with loculated abscesses or intraabdominal sepsis are more likely to undergo surgical revision. Endoscopic therapy is an appropriate first-line modality for the management of SGLs, especially those not classified as acute or chronic.

KW - Endoscopy

KW - Leak

KW - Sleeve gastrectomy

UR - http://www.scopus.com/inward/record.url?scp=85065793580&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85065793580&partnerID=8YFLogxK

U2 - 10.1016/j.soard.2019.04.009

DO - 10.1016/j.soard.2019.04.009

M3 - Article

JO - Surgery for Obesity and Related Diseases

JF - Surgery for Obesity and Related Diseases

SN - 1550-7289

ER -