World Journal of Gastroenterology · 5 authors, 5 centres
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Post-bariatric surgical leaks and fistulas are the most feared complications of bariatric surgery, with incidence ranging from 0.4% to 5.6%. Endoscopic therapy has become the first-line treatment, with several techniques available including closure, covering, and draining approaches. Early diagnosis and individualized treatment based on defect characteristics and patient stability are critical for achieving high closure rates, with clinical success up to 90% when treated within 3 weeks.
**Background:** Post-surgical leaks and fistulas are the most feared complications of bariatric surgery, with incidence ranging from 0.4% to 5.6% after RYGB and 1.9% to 5.3% after LSG, and higher rates after revisional surgeries. Traditionally treated surgically with high morbidity and mortality, endoscopic therapy has become essential. Leaks are defined as transmural defects with communication between intra and extraluminal compartments, while fistulas are abnormal communications between two epithelialized surfaces. Classification is based on time of onset (acute <7 days, early 7 days-6 weeks, late 6 weeks-3 months, chronic >3 months) and location.
**Methods:** This narrative review summarizes current scientific evidence and the authors' extensive experience to provide recommendations for choosing the best endoscopic approach. The authors describe multiple endoscopic techniques classified by mechanism of action: closure techniques (cap-mounted clips, tissue sealants/glues, endoscopic suturing), covering techniques (conventional esophageal stents, customized bariatric stents, cardiac septal defect occluders), and draining techniques (endoscopic vacuum therapy, endoscopic internal drainage with double pigtail stents, septotomy).
**Key Results:** Cap-mounted clips show clinical success of 63.5% as single therapy and 86.3% when combined with other therapies. SEMS demonstrate efficacy of 76.1% for RYGB and 72.8% for LSG leaks, but with high migration rates (RYGB: 30.5%, LSG: 28.2%). CSDO achieves 97.1% clinical success for late/chronic defects versus 62.5% for acute/early scenarios. EVT shows pooled clinical success of 87.2% with 6% adverse event rate, requiring mean 6.47 exchanges at 4.39-day intervals. EID with DPS demonstrates 89.5% success for leaks and 78.5% for fistulas in the largest study (617 patients), with 13.8% adverse event rate. Septotomy achieved 100% clinical success in a study of 27 patients after 1-6 sessions over average 18.11 days. Endoscopic suturing showed 100% technical success but only 22.4% clinical success at one-year follow-up. Tissue sealants/glues showed pooled closure rate of 96.8% in meta-analysis, though the authors note this does not reflect their experience.
**Clinical Implications:** Endoscopic therapy is now first-line for post-bariatric leaks and fistulas, except in unstable patients with undrained uncontained collections where surgical approach is preferred. Early diagnosis and treatment within 3 weeks yields closure efficacy up to 90%, dropping to approximately 70% after this period. Treatment must be individualized based on patient clinical condition, defect characteristics (size, chronicity, associated collections), device availability, and local expertise. Draining of associated collections and treatment of related factors (downstream stenosis dilation, foreign body removal) are fundamental principles. The authors recommend a structured algorithm: for acute/early leaks with undrained contained collections, endoscopic drainage techniques (intracavitary EVT or EID with DPS) are preferred; for late/chronic fistulas, CSDO with or without tissue sealants is recommended; septotomy should be performed whenever a septum is identified. Multidisciplinary care in tertiary referral centers is ideal given the complexity of these cases.