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

Table 4 Suggested recommendations on management of post bariatric surgical leaks and fistulas

Leak or fistula characteristics + patient clinical condition	Recommended management (first line approach)	Possible therapy (second line approach)	Possible endoscopic therapies based on defect characteristics
Acute and early leaks with undrained uncontained collection in unstable patients	Surgical lavage + external drainage (surgical placement) ± surgical repair ± endoscopic therapy (see column 4)	Image-guided external drainage + endoscopic therapy (see column 4) OR Intracavitary EVT	Defect < 2 cm: Cap mounted clips OR stents OR intraluminal EVT; Defect > 2 cm: Stents OR intraluminal EVT; If a septum is diagnosed (early): Septotomy must be performed
Acute and early leaks with undrained uncontained collections in stable patients (rare condition as most patients with undrained uncontained collections presents with peritonitis/sepsis)	Image-guided external drainage + endoscopic therapy (see column 4)	Surgical lavage + external drainage (surgical placement) ± surgical repair ± endoscopic therapy (see column 4) OR Intracavitary EVT	Defect < 2 cm: Cap mounted clip OR stents (prefer stents if associated with downstream stenosis) OR intraluminal EVT; Defect > 2 cm: Stents OR intraluminal EVT; If a septum is diagnosed (early): Septotomy must be performed
Acute and early leaks with undrained contained collections (both unstable or stable patients - most of these patients are stable due to the contained collection)	Endoscopic drainage techniques: Intracavitary EVT OR EID with DPS; If a septum is identified, septotomy must be performed	Image-guided external drainage + endoscopic therapy (see column 4)	Defect < 2 cm: Cap mounted clips OR stents (prefer stents if associate with downstream stenosis) OR intraluminal EVT; Defect > 2 cm: Stents OR intraluminal EVT; If a septum is diagnosed (early): Septotomy must be performed
Late and chronic leaks (both unstable or stable patients - most of these patients are stable as uncontained collection are extremely rare in late and chronic leaks)	Endoscopic drainage techniques: EID with DPS OREVT (intracavitary if associated collection > 3 cm); If a septum is identified, septotomy must be performed	Image-guided external drainage + endoscopic therapy (see column 4) OR Surgical approach	Defect < 2 cm: Cap mounted clips OR CSDO OR tissue sealants/glues (as an adjunctive therapy); Defect > 2 cm: CSDO OR tissue sealants/glues (as an adjunctive therapy)
Late and chronic fistulas (both unstable or stable patients - most of these patients are stable)	Endoscopic therapy (see column 4); Cytology brushing or APC to loosen granulation tissue before endoscopic therapy is helpful; If a septum is identified, septotomy must be performed	Surgical approach	Defect < 2 cm: CSDO ± tissue sealants/glues OR tissue sealants/glues ± cap mounted clips OR tissue sealants/glues + intraluminal EVT; -Defect > 2 cm: CSDO ± tissue sealants/glues OR tissue sealants/glues + intraluminal EVT,
Late and chronic gastro-gastric fistula	Defect < 10 mm: Endoscopic therapy (see column 4); Defect > 10 mm: Surgical approach	Surgical approach after endoscopic management failure	APC ± CSDO ORAPC + suturing OR APC + cap mounted clip

APC: argon plasma coagulation; CSDO: Cardiac septal defect occluder; DPS: Double pigtail stents; EID: Endoscopic internal drainage; EVT: Endoscopic vacuum therapy.