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

Table 3 Endoscopic draining techniques

Endoscopic techniques	Indications/advantages	Not indicated/disadvantages	Authors experience
Endoscopic vacuum therapy	(1) Acute/ early/ late/ chronic; (2) High efficacy in leaks and fistulas with or without associated collection; (3) No need for external drainage; (4) Superior to stent in upper GI tract; and (5) Unique mechanism of action: macro-deformation/ micro-deformation, changes in perfusion/ angiogenesis/exudate control/bacterial clearance	(1) Inability to achieve negative pressure; (2) No endoscopic access; (3) Patient discomfort related to nasogastric tube; (4) Usually repeated procedures are needed (especially when traditional sponge is used); and (5) Longer hospital stay/ high costs (?)	(1) Acute/ early/ late/ chronic; (2) Very high clinical success rates; (3) You must place the EVT system in intracavitary position when an associated collection is identified; (4) Placement of both intracavitary and intraluminal EVT appears to be the best approach; (5) Traditional sponge: challenging placement and removal (mouth), prolonged procedures, and need for multiple exchanges (6) Low-cost modified EVT: easy placement and removal, reduction in procedure time, longer interval between EVT system exchanges, low cost, and low AEs rates; and (7) Modified triple-lumen EVT: drainage and nutrition with one tube through the nares
Endoscopic internal drainage with double pigtail stent	(1) Acute/early/late/chronic; (2) High efficacy; (3) No need for external drainage; (4) Need of an associated collection; (4) Easy placement (7fr – gastroscope); (5) Small or large orifices; and (6) Short hospital stay	(1) Defects without an associated collection; (2) No place to accommodate the DPS (small collection: < 2 cm); (3) Long period for complete healing; (4) Risk of migration, perforation and bleeding; and (5) Usually, fluoroscopy is needed	(1) Acute/ early/ late/ chronic; (2) High clinical success rates; (3) Small orifices with associated collection; (4) Easy placement; (5) Shorter hospital stay/ electives procedures for DPS exchanges; (6) Faster oral intake (start with clear liquids); (7) Better patient acceptance – no symptoms; (8) Long period for complete healing; and (9) Ureteral stents appear to be safer with similar efficacy
Septotomy	(1) Early/late/chronic (> 15 d); (2) High efficacy; (3) Safe; (4) Septum between the orifice/ collection and the gastric lumen; and (5) Must do it when a septum is identified	It is only performed when a septum is identified	(1) Early/late/chronic (> 15 d); (2) Very high clinical success; (3) Usually more than 1 session is required; (4) Cut until the staple line; (5) APC or Knife (APC < bleeding); (6) Always dilate after septotomy; (7) Outpatient procedure; and (8) Septum is the cause of most late/chronic refractory defects treated in a center without experience

APC: Argon plasma coagulation; DPS: Double-pigtail stents; EVT: Endoscopic vacuum therapy; GI: Gastrointestinal.