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Endoscopic Treatment of Post-Bariatric Leaks

par Eisendrath, Pierre
Président du jury Melot, Christian
Promoteur Devière, Jacques
Publication Non publié, 2016-11-21

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Résumé :

The prevalence of post-bariatric complications and post-bariatric leaks has dramatically increased over the last two decades, in line with the pandemic of morbid obesity and the growing number of bariatric surgeries. For bariatric leaks, re-operation with drainage, and possibly an attempt at surgical closure, has, for a long time, been considered as the only possible treatment.In the early 2000s, our team started to be involved in post bariatric complications management and, with the experience we acquired in other diseases associated with upper gastrointestinal leakages, endotherapy became logically a good theoretical option to treat these leaks. It offers a potentially less invasive alternative to an unsatisfactory surgical management.Insertion of a self-expandable stent to cover the leak and facilitate its closure was our initial treatment strategy. Our retrospectives studies in this field, in addition to demonstrating good results, helped to identify major clinical factors associated with treatment success, such as early endoscopic management after leakage diagnosis. We promoted the use of partially covered stents which helps to reduce the risk of migration, probably increases watertightness, and can be efficiently extracted after the insertion of a fully covered stent.However, post bariatric leaks is a serious and difficult clinical situation and we experienced disappointing results with stent treatment alone in several patients. This led us to develop complementary techniques, such as fistula plug insertion or internal drainage with double pig tail stents, which provided additional positive results. Internal drainage even appears to be effective as an isolated strategy in selected patients.The present work illustrates the evolution of this new clinical modality and demonstrates, based on our published results, how endotherapy has become a first-line option that now plays a pivotal role in the multimodal approach to post-bariatric leakage. We show that, in the hands of an experienced team and with treatment tailored to the variety of clinical presentations, endotherapy can reach almost 90% success. Based on our results and on our current experience, we propose a treatment algorithm for management of post bariatric leaks and fistulas in which deployment of intraluminal self-expandable stents remains the cornerstone.As prospective and comparative study for management of this life-threatening complication are lacking, we also propose several direction for future clinical researches in this area which could help to standardize the multimodal treatment of post-bariatric leaks.