SEARCHNARRATIVE_REVIEWsurgery, gastroenterology

narrative_review·surgery, gastroenterology, internal medicine, critical care, nutrition·PMC10011956

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

World Journal of Gastroenterology · 5 authors, 5 centres

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TL;DR

This narrative review synthesizes evidence and expert experience on endoscopic management of post-bariatric surgical leaks and fistulas, concluding that endoscopy is first-line therapy for stable patients while unstable patients with uncontained infections require surgery.

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This narrative review addresses endoscopic management of post-surgical leaks and fistulas following bariatric surgery, which are the most feared complications of such procedures. The authors distinguish leaks (transmural defects with intra- and extraluminal communication) from fistulas (abnormal communication between two epithelialized surfaces) and discuss endoscopic techniques categorized by mechanism of action: direct closure, covering/diverting, or draining. The review emphasizes that patients with tachycardia, fever, and intense abdominal pain require immediate surgical revision, whereas stable patients benefit from endoscopic therapy as first-line treatment. The authors note that acute leaks and fistulas have higher clinical success rates with endoscopic treatment compared to late and chronic ones. Multidisciplinary care is recommended, ideally at tertiary referral centers.

STUDY TYPE

narrative_review

SPECIALTY

surgery

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ORIGINAL PAPER

PMC10011956

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

World Journal of Gastroenterology

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ABSTRACT

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

CITATION EXPORT

Victor Lira de Oliveira, Alexandre Moraes Bestetti, Roberto Paolo Trasolini et al.. Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations. World Journal of Gastroenterology. (2023). https://doi.org/10.3748/wjg.v29.i7.1173

AUTHORS

5 · 5 CENTRES

Victor Lira de Oliveira, Alexandre Moraes Bestetti, Roberto Paolo Trasolini, Eduardo Guimarães Hourneaux de Moura, Diogo Turiani Hourneaux de Moura

Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
Division of Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 021115, United States
Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil. [email protected]