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

Table 1 Endoscopic closure techniques

Endoscopic techniques	Indications/advantages	Not indicated/disadvantages	Authors experience
Cap-mounted clips	(1) Acute/ early/ late/ chronic; (2) Small orifices (< 20 mm); and (3) Safe	(1) Orifices > 20 mm; (2) Need for external drainage; and (3) Variable efficacy	(1) Acute/ early/ late/ chronic; (2) Safe; (3) < 10 mm: > efficacy; (4) > 10mm: very low efficacy; (5) Combined therapy improves its efficacy; and (6) Can be removed when fails to close the defect (not easy to remove)
Glues/ tissue sealants	(1) Acute/ early/ late/ chronic; (2) Diameter < 10 mm; (3) Low drainage (< 200 ml/24 h); and (4) Safe	(1) Multiple sessions are usually required; (2) Need for external drainage; and (3) Variable efficacy	(1) Late/ chronic; (2) Low efficacy; (3) Safe; (4) Helpful as an adjunctive therapy; (5) Never use it as a single therapy; (6) Multiple sessions; (7) Cytology brushing or APC is useful to loosen granulation tissue before application; (8) Delivery via endoscopic or percutaneous access; and (9) High cost (tissue sealants)
Endoscopic suturing	(1) Acute/ early/ late/ chronic; (2) High technical success; and (3) Safe	(1) Need for external drainage; (2) Low efficacy (need for robust and healthy tissue for primary closure); (3) Challenging: Previous experience with the device is needed; and (4) High costs (most countries)	(1) Very poor long-term clinical success; (2) Helpful for other devices fixation; (3) Not recommended for chronic defects; and (4) High cost

APC: Argon plasma coagulation.

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.

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.

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.