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

Table 2 Endoscopic covering techniques

Endoscopic techniques	Indications/advantages	Not indicated/disadvantages	Authors experience
Conventional (esophageal) stents	(1) Acute/ early; (2) Satisfactory efficacy; (3) Very popular; (4) Widely available; (5) International guidelines support; (6) Easy placement; (7) Early oral intake; and (8) Low number of repeated procedures	(1) Late/ chronic; (2) High migration rates; (3) Need for external drainage; (4) Mild symptoms related to the stent; and (5) Possible “surprise” when removing it	(1) Acute/ early; (2) Satisfactory efficacy; (3) Easy placement/ not expensive; (4) Helpful for complete dehiscence; (5) PCSEMS > FCSEMS (challenging removal – do not keep it for > 3 wk); and (6) High migration rates (FCSEMS)
Bariatric stents	(1) Acute/Early; (2) Satisfactory efficacy; (3) “Perfect” shape for LSG leaks; (4) Low number of repeated procedures ; and (5) Easy placement	(1) Late/ chronic; (2) High migration rates; (3) Need for external drainage; (4) Severe symptoms related to the stent; and (5) Possible “surprise” when removing it	(1) Acute/ early; (2) Similar efficacy to the conventional stent; (3) More expensive than the conventional stent; (4) Helpful for downstream stenosis and complete dehiscence; (5) Pre-pyloric position: more symptoms; (6) Post-pyloric position: more migration; (7) High rates of adverse events (ulcers and perforations); and (8) Intolerance due to symptoms related to the stent (GERD, pain, and emesis)
Cardiac septal defect occluder	(1) Late/ chronic; (2) High efficacy; (3) Safe; and (4) Epithelialized surface is required for device fixation	(1) Need for external drainage; (2) Off-label use; (3) High cost; and (4) Acute and early: enlargement and migration if no epithelialized surface	(1) Very high efficacy for late/ chronic defects with epithelialized tract without associated collection; (2) Safe; (3) High cost; (4) Off-label; (5) Indicated after conventional techniques failure; and (6) Size selection based on defect size (2:1)

FCSEMS: Fully covered self-expandable metal stents; GERD: Gastroesophageal reflux disease; LSG: Laparoscopic sleeve gastrectomy; PCSEMS: Partially covered self-expandable metal stents.