Status of bariatric endoscopy–what does the surgeon need to know? A review

Table 1 Endoscopic closure and occlusion techniques for the treatment of leaks and fistulas after bariatric surgery

Endoscopic technique	Indications/advantages	Not indicated/disadvantages	Our experience
Glues (Closure)	(1) Acute/early/late/chronic; (2) Low-debit (< 200 mL/24 h); (3) Diameter < 10 mm; and (4) Safe	(1) Multiple sessions are usually required; (2) High costs; (3) Need for external drainage; and (4) Variable efficacy	(1) Low efficacy; (2) Multiple sessions; (3) High costs; (4) Late/chronic; (5) Combined approach; and (6) Can be used in select cases
Cap-mounted clips (Closure)	(1) Acute/early/late/chronic; (2) Small orifices (< 2 cm); and (3) Safe	(1) > 2 cm orifice; (2) Need for external drainage; and (3) Variable efficacy	(1) Low efficacy; (2) Late/chronic; and (3) Can be used in select cases
Suturing (Closure)	(1) Acute/early/late/chronic; and (2) Safe	(1) Need for external drainage; (2) Challenging-need previous experience with the device; (3) Low efficacy; and (4) High cost	(1) High cost; (2) Very poor long-term clinical success; and (3) We do not recommend it!
Stents (conventional esophageal or specific design for LSG) (over)	(1) Acute and early; (2) Very popular; (3) Efficacy > 70%; (4) Conventional = bariatric stent; (5) Early oral intake; and (6) Lower number of repeat procedures	(1) High rates of migration (up to 30%); (2) Need for external drainage; (3) Symptoms related to the stent; (4) Late and Chronic; and (5) You may have a “surprise” when remove it	(1) High rates of migration; (2) Partially covered > fully-covered (challenging to remove-do not keep it for more than 3 wk!); and (3) Bariatric stents: Similar efficacy, more SAE; Symptoms related to the stent (pre pyloric); More migration (post pyloric); We´re avoiding stents, specially Bariatric Stents
Cardiac septal defect occlude (Cover)	(1) Late and chronic; (2) Efficacy > 95%; and (3) Safe	(1) Off-label use; (2) Acute and Early; (3) High cost; and (4) Need for external drainage	(1) High efficacy in late/chronic fistulas with epithelialized tract without associated collection; (2) Safe; and (3) Good option after failure of conventional techniques

Table 2 Endoscopic drainage techniques for the treatment of leaks and fistulas after bariatric surgery

Endoscopic technique	Indications/advantages	Not indicated/disadvantages	Our experience
Septotomy	(1) You must do it when a septum is identified; (2) Early, late and chronic; (3) High efficacy: 80%-100%; and (4) Safe	It is just performed when a septum is identified!	(1) Very high clinical success rates; and (2) Septum is the cause of most late and chronic leaks/fistulas treated in a center without experience
EVT	(1) Acute, early, late and chronic; (2) High efficacy (> 90%) in leaks with or without associated collection; (3) No need of external drainage; and (4) Superior to stent in upper GI tract	(1) Patient discomfort related to NGT; (2) Usually repeat procedures are needed (sponge); (3) Respiratory/Cutaneous fistula; (4) Longer hospital stay (?); and (5) High costs (?)	(1) Very high clinical success rates; (2) Modified EVT: Easy placement, reduction in procedure time and need for repeat procedures, lower costs and Aes; and (3) Modified trelumina EVT: Drainage and nutrition with one tube through the nares
DPS	(1) Acute, early, late and chronic; (2) High efficacy (> 85%) in leaks/fistulas with associated collection; (3) Easy placement (7fr-gastroscope); (4) No need of external drainage; and (5) Short hospital stay	(1) Longer period for complete healing; (2) Risk of migration and bleeding; (3) No place to accommodate the stent in small collections; and (4) Usually fluoroscopy is needed	(1) Very high clinical success rates; (2) Shorter hospital stay; (3) Faster oral intake (clear liquids); and (4) Better patient acceptance–no symptoms

EVT: Endoscopic vacuum therapy; DPS: Double-pigtails stents; SAE: Severe adverse events; Aes: Adverse events.