Endoscopic Stents in the Management of Bariatric Complications: Our Algorithm and Outcomes

Background: Endoscopic techniques can provide an alternative to surgery in the management of post-bariatric surgery complications such as leaks, strictures, fistulas, and erosion of transgastric and adjustable gastric bands. Endoscopically placed stents can also be used to manage gastric perforations secondary to NSAIDS or perforated marginal ulcers following gastric bypass surgery. Additionally, stents can be used in conjunction with operative intervention to decrease the risk of more deleterious complications that could require additional operations.

Objectives: The objective of this report is to describe our private practice experience in managing bariatric procedure complications with fully covered endoscopic stents. We present the algorithm we use in the application of endoscopic stents in the management of complications following bariatric surgery.

Setting: Private practice, Single provider, Tertiary Referral Center, USA METHODS: Data for all patients who underwent endoscopic stent placement for complications after various bariatric surgeries (Roux-en-Y gastric bypass, gastric sleeve, lap band, and vertical banded gastroplasty) performed by several different surgeons between July 2015 and December 2018 at a single private practice were retrospectively reviewed. Patient's medical history, perioperative information, stent placement details, outcomes, and subsequent interventions were reviewed and analyzed.

Results: Thirty-five patients who were treated with endoscopic stents after bariatric surgery were identified. Complications after bariatric surgery treated with stenting included staple line leaks, anastomotic leaks, strictures, marginal ulcer perforations, gastrogastric fistula, and lap band erosion repairs. Mean duration of each stent round also varied. Resolution occurred in 33 patients (94.3%). Stent migration occurred in seven patients (20%) and in eight of 51 stents placed (15.7%). Two patients ultimately required revision surgery, though only one was related to stent (2.9%).

Conclusions: Our findings suggest that foregut stents deployed according to our algorithm can facilitate healing of anastomotic leaks, staple line leaks, and marginal ulcer perforations. Furthermore, stent placement can also bolster tenuous repairs of band erosion sites, repairs staple line failure, and manages leaks at band erosion repair sites. Endoscopic stents can also be utilized to augment both balloon and savory dilation of gastric anastomoses and gastric sleeve strictures. Stents should be clipped proximally and distally to minimize the risk of migration.