Temporary Covered Stents for the Treatment of Anastomotic Leaks Following Gastric Bypass Surgery

by Jerome Lyn-Sue, MD; Kimberley Steele, MD; Michael A. Schweitzer, MD; Thomas Magnuson, MD; Anne Lidor, MD; Anirban Gupta, MD; and Patrick Okolo, MD.

All from Johns Hopkins University School of Medicine, Baltimore, Maryland.

Introduction
Roux-en-Y gastric bypass is the most effective and most commonly performed bariatric surgical procedure in the United States.1 While improvements in surgical technique have significantly reduced postoperative complication rates, anastomotic leak continues to occur and remains an important cause of postoperative morbidity and mortality.2 Repair of an anastomotic leak may involve open or laparoscopic surgical re-exploration, which can contribute to the morbidity of this life-threatening complication.3 A transoral endoscopic approach, using a covered stent, has the potential to avoid further morbidity from a potentially difficult intra-abdominal attempt at repairing the hole. Covered stents have been used for esophageal anastomotic leaks following non-bariatric procedures with good success. Several reports have described the effective use of this therapy for such leaks, as well as for malignant esophageal fistulas.4,5

Recently, this technique has been applied to the treatment of gastrojejunal anastomotic leaks after gastric bypass surgery, and early reports have been encouraging.6 We describe the successful use of a removable covered plastic stent for gastrojejunostomy-associated anastomotic leak following Roux-en-Y gastric bypass.

Case Report
A 48-year-old male weighing 469 pounds, with a body mass index (BMI) of 65kg/m2, underwent open Roux-en-Y gastric bypass. His medical history was significant for hypertension, type 2 diabetes mellitus, obstructive sleep apnea, lower extremity edema, osteoarthritis, and thombophilia secondary to lupus anticoagulant, which required chronic warfarin therapy. The postoperative course was uneventful, and an upper gastrointestinal (GI) study revealed no leak or other abnormality. The patient was discharged home on enoxaparin, with plans to resume warfarin therapy as an outpatient.

Ten days postoperatively, he presented to the emergency room complaining of abdominal pain, fever, and postprandial vomiting. Abdominal computed tomography (CT) revealed a fluid collection in the left upper quadrant, which was drained percutaneously. Upper gastrointestinal series revealed a leak at the gastrojejunostomy. Antibiotic coverage was initiated, and enteral nutrition was started via the gastrostomy tube that had been placed at the time of his original surgery.

Upper endoscopy revealed a defect at the gastrojejunal anastamosis with visualization of the percutaneously placed intraperitoneal drain. A polyflex stent (Boston Scientific, Natick, Massachusetts) measuring 25mm by 15cm was deployed under direct and fluoroscopic guidance to cover the defect (Figure 1). Administration of oral contrast revealed no extravasation after stent placement (Figure 2). He was started on a clear liquid diet within 48 hours of stent placement.

Approximately two weeks following placement of the stent, increased drain output was noted. An upper GI study revealed contrast extravasation. Upper endoscopy revealed migration of the initial stent, which was removed, and overlapping stents were placed under fluoroscopic guidance. Again, no contrast extravasation was seen on post-procedure fluoroscopy, and output from the intraperitoneal drain decreased. At three-month follow-up, the patient was tolerating a bariatric diet with minimal drain output. The stents were removed endoscopically without incident. Subsequently, the surgical drain and gastrostomy tube were removed after the patient demonstrated the ability to tolerate a diet. At 12-month postoperative follow-up, the patient was noted to be doing well with an overall weight loss of 205 pounds and a reduction in BMI from 65kg/m2 to 37.5kg/m2.

Discussion
A gastrointestinal leak is one of the leading causes of mortality after gastric bypass. Possible risk factors for a leak include advanced age, male sex, increased BMI, type II diabetes mellitus, continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea, and revisional surgery.7 A leak after gastric bypass may occur at the gastrojejunostomy, the gastric pouch staple line, the distal stomach staple line, or the jejunojejunostomy. The majority of leaks occur at the gastrojejunostomy anastomosis.8 Small, contained leaks can be treated with percutaneous drainage. When re-exploration is required, the main objectives are to identify the location of the leak and provide drainage. Repairing of the breakdown by simple sutured closure may not be possible if the tissue is inflamed and friable.

Patients who have a gastrojejunostomy or a gastric pouch leak that is small or contained may also be candidates for transoral endoscopic therapy. This nonoperative approach to gastrointestinal leak treatment is evolving rapidly with the use of temporary plastic coated stents, fibrin glue, endoscopic clips, and endoscopic suturing.7

Stents are currently being used for both esophageal and colonic strictures. They have been used in treatment of malignant tracheoesophageal-fistulas, and more recently in the treatment of esophageal perforations and anastomotic leaks.4,5 There have been recent reports of stents used in patients with anastomotic leaks at the gastrojejunostomy after gastric bypass. These studies reported successful placement of covered stents (Polyflex, Boston Scientific, Natick, Massachusetts) and metallic stents to treat this condition. The patients were able to tolerate oral feeding within 2 to 3 days after stent placement.6,9

Merrifield, et al., described stent placement as well as other endoscopic methods to assist in closure of anastomotic leaks. They used Triclip (Cook Endoscopy, Winston-Cook, Winston-Salem, North Carolina) with argon plasma coagulation to promote closure. Resolution clips (Microinvasive Endoscopy, Boston Scientific, Natick, Massachusetts), Quick Clips (Olympus America Inc., Melville, New York) and the Bard EndoCinch device (CR Bard Inc, Murray Hill, New Jersey) have also been described as treatment options.10-12 Human fibrin tissue sealant has been used alone or in combination with endoscopic clips for the endoscopic management of gastrocutaneous fistula after bariatric surgery. In these cases, multiple procedures may be needed with varying volumes of glue to control the leak. The fibrin glue applications were found to initially reduce the drainage output from abdominal drains. The mechanism of action was shown to be occlusion of the inner orifice, the main drainage tract and septic cavity if present.13

The majority of patients previously reported with gastrojejunostomy leaks managed with stent placement had containment of the leak and were able to tolerate oral nutrition. These patients underwent removal of the stents after resolution of the leaks. Removal appears to be much easier with plastic stents than with metallic stents, as the latter have been associated with esophageal mucosal tears. However, plastic stents appear to suffer from the drawback of being prone to distal migration. Migrated stents can be managed with endoscopic removal, or can be allowed to pass through the gastrointestinal tract.6,9 Our patient experienced stent migration, necessitating removal and replacement of the stent. Overlapping stents or fixation with clips may help to lessen the risk of migration.

Conclusion
In summary, transoral endoscopic stent placement is a viable option for treatment of anastomotic leaks after gastric bypass. Because of the potential for partial- or full-thickness esophageal injury during removal of metallic stents, covered plastic stents are preferred. However, these removable stents are prone to migration and require careful followup. Finally, transoral endoscopic treatment for gastrointestinal leak should be considered only in stable patients with small and/or contained leaks that are adequately drained.

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Address for correspondence:
Jerome Lyn-Sue, Johns Hopkins Bayview Medical Center, Department of Surgery, 4940 Eastern Avenue, Baltimore, MD 21224; Phone: (410) 550-6714;
Fax (410) 550-1245;
E-mail: [email protected].

Category: Case Report, Past Articles