Endoscopic Treatment of Bariatric Surgery Complications

by Jose M. Martinez, MD, FACS, and Atul K. Madan, MD, FACS

Both from the Division of Laparoendoscopic and Bariatric Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.

INTRODUCTION

Bariatric surgery has shown to be the most successful way to lose excess body weight for those patients that meet the criteria of morbidly obese.[1–3]Although today’s standard bariatric operations are quite safe, a number of complications may be encountered. Early in the experience of bariatric surgery, some of these complications required repeat surgery, which carries a greater rate of complications. Over the past decade, the flexible endoscope has become a more aggressive tool with increased therapeutic potential to add to its diagnostic tradition. Many of the endoscopic treatments are associated with less morbidity and/or mortality.Some of the common complications after bariatric surgery will be reviewed in this article. We will discuss the current endoscopic options available prior to undergoing repeat surgical intervention.

Stricture
One of the more commonly encountered complications after Roux-en-Y gastric bypass is a stricture at the gastrojejunostomy. Another possible but less likely site of a stricture is at the jejunojejunostomy. The most appropriate initial management of a gastrojejunal anastomotic stricture is to perform an endoscopic dilatation. While some have used bougie dilation successfully,[4] we feel that balloon dilation with or without flouroscopic guidance offers the safest method. The balloon is passed through the working channel of the endoscope. The dilation may be monitored under fluoroscopic guidance (Figure 1 and Figure 2). A key step is the ability to traverse the anastomosis to ensure the balloon is intraluminal on the distal side of the anastomosis to decrease the incidence of perforation. This is achieved by traversing the stricture with a guidewire. The wire is then followed with catheters that allow injection of contrast under fluoroscopy to demonstrate it has safely traversed the stricture and is in the small bowel. If the anastomosis can be traversed with an adult-sized endoscope, dilation may not be needed. Instead, dietary re-education is often the best course of action. We discourage dilation with wire- or non-wire-guided bougie dilator because of the increased risk of injury to the often angulated small bowel just distal to the anastomosis. Dilating balloon catheters come in multiple diameters (Figure 3). The goal is to achieve an inner lumen similar to the original surgery. The most commonly used size is 13 to 15mm diameter, so the resulting anastomosis post-healing will be in range of 10 to 12mm. This technique is highly effective but may require repeat dilation, which still results in good success.[5–7] The most common but still rare complications encountered from balloon dilation are bleeding and perforation.[5–7] One concern about dilation of a stricture that is not often discussed is the possibility of increasing the diameter to the point of creating a gastrojejunostomy that is too large to keep food into the stomach. If the gastric pouch is not distended, there is worry that satiety may be lost, which may result in weight gain.

Rarely, patients will be refractory to balloon dilatation.[8, 9] This patient population would previously be referred for corrective surgery. Today, new endoscopic technology allows for attempts at other options prior to proceeding to surgery.[9,10] In such case, a self expanding plastic stent (polyflex) designed for benign disease, can be placed across the stricture and removed in 4 to 6 weeks (Figure 4). These stents are designed to have little incorporation to tissue to allow removability in the future. Flares have been designed so as to limit the possibility of stent migration. Stent management of refractory strictures has been shown to be very successful despite the expected potential complications of bleeding, perforation, and stent migration. Another intervention for the refractory cases is to perform a stricturotomy.[10] This can be performed with a needle knife catheter or laser to score the scar tissue longitudinally in two or three quadrants (Figure 5). Risks of bleeding and perforation are the highest for this intervention compared to the other mentioned options and therefore reserved when others have failed.

Fistula/Leaks
The management of postoperative leaks/fistulas has been more controversial in recent years with the advent of endoscopic interventions that may save some patients from reoperative surgery. While acute leaks can be treated with laparoscopic intervention, they are not without some mortality.[11] This group of procedures includes emergent, urgent, and elective interventions. These complications can occur after Roux-en-Y gastric bypass or sleeve gastrectomy. Such complications include gastrogastric fistula, gastrojejunostomy fistula, gastric pouch/sleeve leak, or gastrojejunostomy leak. Leaks are likely needed to be controlled with external drainage so that they can be managed nonoperatively. Obviously, leaks that are not treated surgically depend on the fact that the patient is in stable condition. These leaks may be excluded with an endoluminal, self-expanding plastic stent (polyflex) that extends from the esophagus to the duodenal (Figure 4).[9] Often, two-tunneled stents are required to bridge this long path and exclude the fistula tract.

Prior to stents being deployed, other simpler endoscopic modalities may be tried for leaks or fistulae. Endoscopic clips can be used to reapproximate the defect and fibrin glue products can be injected into the fistula tract (Figure 6 and Figure 7).[12–14] Success in these interventions is limited to case reports/series.[12–14] Our recommended approach is to combine all the modalities to achieve the best possible result the first time as this may be the best, if not only, opportunity prior to having to undergo surgery. First, the mucosa is scrapped/burned to stimulate adhesion, followed by injection of glue into the tract. Then, the opening is closed with endoscopic clips. Finally, the site of the leak or fistula is ultimately bypassed with placement of a stent. Keep in mind that many of these interventions have not been largely studied and have uncertain results. The decision for surgical intervention to repair any of these complications should be considered depending on the status of the patient’s overall condition.

Gastric Remnant/Biliary Access
The gastric remnant and biliary tree are two difficult areas to evalulate post-Roux-en-Y gastric bypass. Gastritis, ulcers, polyps, tumors, and bleeding are some of the common indications to evaluate the gastric remnant post-bariatric surgery. Abnormal liver function tests, biliary dilation, choledocholithiasis, biliary pancreatitis, cholangitis, ampullary pathology, or biliary stricture are reasons to further evaluate the biliary tree. While magnetic resonance cholangiopancreatography (MRCP) can be utilized for diagnostic purposes, therapeutic approaches to this area are usually via transoral route, percutaneous route, or a combined laparoscopic/endoscopic route.

Traditionally, it has been difficult to reach the gastric remnant post Roux-en-Y gastric bypass as more than 200cm of intestine and two anastomoses need to be traversed to reach it via a transoral route in a retrograde fashion.[15–17] Either an enterosocope or balloon enteroscopy is used to reach the remnant more successfully. However, these scopes are long with smaller working channels and sometimes limit therapeutic procedures that may need to be performed. Furthermore, few centers had the experience or ability to perform this procedure. Even in those with some experience, the success rate of reaching the excluded stomach is not high.[15]

Another approach to the gastric remnant is a percutaneous route. Access to the gastric remnant is gained via a gastrostomy tube place under fluoroscopy, computerized tomography (CT), or ultrasound guidance.[18–20] Once the tract matures, a gastroscope is introduced via the tract and diagnostic and therapeutic interventions may be performed. The benefits of this approach are the ease of scope management and ability to use traditional scope and equipment. It also eliminates the need for general anesthesia or surgical intervention. The major limitation of the percutaneous route is that it is not an appropriate option for any urgent or emergent intervention as the gastrostomy needs to be placed, the tract needs to mature prior to scoping, and dilation of the tract needs to occur. These procedures take time to accommodate larger diameter scopes to perform any required therapeutic intervention.

For emergent or urgent cases, a similar percutaneous approach may be gained under laparoscopic assistance that allows for insertion of the desired endoscope into the gastric remnant. Once the gastric remnant is reached, the pathology can be managed with traditional endoscopic interventions for control of hemorrhage or biopsy/resection of pathology in question.21 Similarly, pathology requiring access to the biliary tree may be inspected once the gastric remnant has been reached.[21, 22]

If the transoral route was taken, the anatomy will be opposite of normal as the ampulla was reached in a retrograde fashion. This is of particular importance if a sphincterotomy is to be performed because a Billroth II sphincterotome catheter is required to make the cut in the appropriate direction. If access was gained percutaneously via a gastrotomy tube tract or laparoscopically assisted, then the anatomy and orientation to the ampulla are the same as usually seen in the regular population.

Removal of a Foreign Body
A number of foreign bodies may be found eroding into the lumen following bariatric procedures. Laparoscopic adjustable gastric bands have potential to erode into stomach.[23] Silastic rings after banded Roux-en-Y gastric bypass have eroded into gastric pouch.[24] Suture and staple material have been identified to be intraluminal with surrounding ulceration, erosion, and stricture.[25, 26] Bezoars are noted after bariatric surgery as well.[27] Many of these can be totally removed or managed endoscopically or at least assist in the surgical intervention.[23–27]

Eroded laparoscopic adjustable gastric bands are often identified via endoscopy. Even if these are cut intraluminally with the endoscope, they are still attached by the port and need a surgical intervention to complete the procedure.[23] If the band can be cut in half at the site where it has eroded into the lumen, it will facilitate the surgical removal of the band as less internal dissection will be required to cut it. If a silastic ring (or other material from a banded gastric bypass) is noted to be eroded intraluminal, this is best managed by transaction and complete removal endoscopically (Figure 8 and Figure 9).[24] Endoscopic scissors are used to cut the ring or, alternatively, an energy source as a needle knife can be used to cut it. Rat tooth forceps are used to grasp the ring, which usually slides out of the tract easily. Free perforation into the abdomen after the endoscopic removal of a silastic ring that has chronically been eroded is a potential concern, but has not been reported. No other intervention is usually done to the erosion site.

Suture material is another frequently encountered foreign body often leading to ulcerations or gastritis at the pouch, anastomosis, and/or jejunum.[25, 26] These are easily managed with a dual working channel upper endoscope to allow one channel to grasp and place tension on the suture and the other working channel to have endoscopic scissors to cut and remove the sutures. Using a single-channel endoscope makes it more difficult as the endoscopic scissors do not cut very well and need the traction on the suture to cut (Figure 10).

A gastric bezoar is another foreign body encountered after bariatric surgery, especially if a band is too tight, an anastomotic stricture is present, or a patient is not compliant with his or her diet. These bezoars can be managed safely and easily via endoscopic interventions.[27] The use of a net allows sweeping of the bezoar and collection into the net to assist in removal. If the foreign body is large or sharp, then a foreign body retrieval hood and rat tooth forceps are recommended for a firm grasp and minimizing injury of the esophagus upon removal of the foreign body (Figure 11).

Weight Regain/Insufficient Weight Loss
We have previously discussed endoscopic revisional bariatric surgery for inappropriate weight loss and/or weight regain.[28] Briefly, there are various options that are available to the patient and surgeon when encountering weight loss issues after Roux-en-Y gastric bypass. Most of these options are based on reducing either the stomach or stoma size. This reduction occurs via endoscopic suturing, endoscopic injection of sclerosing agents, or utilized specialized endoscopic devices. Sclerotherapy, as first mentioned by Spaulding,[29] utilizes sodium morrhuate for its complication of causing stricture with deep injection. We find that about half of the patients have a satisfactory response to this treatment.

Other potential modalities have included the Flexible Endoscopic Suture Device (Wilson-Cook; Winston-Salem, NC),[30] the EndoCinch System,[31] the USGI Endosurgical Operating System (USGI Medical, Inc., San Clemente, CA),[32] and StomaPhyx (EndoGastric Solutions, Inc., Redmond, WA). Decreasing the pouch and/or stoma size demonstrates another concept of endoscopic treatment of bariatric surgery complications. However, which technologies result in the most durable and consistent methods of pouch and/or stoma reduction and subsequent weight loss has yet to be determined. Presently, we perform endoscopic sclerotherapy and StomaPhyx.

Conclusion
Bariatric surgery has experienced continual evolution. From its early days of open surgery to the current standard of laparoscopic surgery, the field is ever-changing and physicians involved in bariatric surgery must continue to be knowledgeable of emerging technologies. Just as the surgery itself is becoming less and less invasive, so is the management of its associated complications. The standard to proceed with surgery for any identified postoperative complication has evolved to much less aggressive interventions.

Therapeutic endoscopy has become a very aggressive field, tackling difficult complications that would have not been performed in the past. That is not only due to the increased aggressiveness of the endoscopist but also to the improved available instrumentation. Stents, glues, clips, energy sources, and suturing devices have expanded the armamentarium to deal with these difficult problems. Although success of many of these endoscopic interventions may be limited in some cases, and no well-designed studies have investigated the many off-label uses of these tools, the ability to provide an intervention with little potential complication and potentially eliminate the need to reoperate on a complex bariatric patient is well worth it. Avoidance of reoperative bariatric surgery as well as the associated morbidity and mortality make endoscopic treatments appealing—not only to surgeons, but also to patients. As instrumentation continues to be developed for natural orifice translumenal endoscopic surgery (NOTES), many of these technologies will have dual application to be used intraluminally and subsequently expand the success and functionality of intraluminal surgery. These developing technologies will continue to assist in the endoscopic treatment of bariatric surgery complications. Bariatric surgeons need to either gain these skills sets or be aware of these newer options available for their patients.

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Category: Past Articles, Review