Bariatric Times - January 2009 - (Page 9)

Bariatric Times • January 2009 Surgical Perspective 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. 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 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 (Figures 6 and 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 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 (Figures 8 and 9).24 Endoscopic scissors are used to cut the ring or, alternatively, an energy source as a needle knife can be 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

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Bariatric Times - January 2009

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