Brian Lacy, MD, and Victoria Gomez, MD on Complications of Bariatric Surgery:Part 2

Drs Lacy and Gomez continue their podcast on complications following bariatric surgery with a discussion of gastric sleeve surgery, an increasingly popular option.

Brian Lacy, MD, is a professor of medicine at Mayo Clinic-Florida in Jacksonville, Florida. Victoria Gomez, MD, is an associate professor of medicine and director of the Bariatric Endoscopy Program at Mayo Clinic-Florida.

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TRANSCRIPT:

Speaker 1:

Welcome back to part two of this podcast with doctors Brian Lacey and Victoria Gomez from Mayo Clinic Jacksonville as they continue their discussion on complications of bariatric surgery.

Speaker 2:

So Victoria, let's shift a little bit now to the other major weight loss surgery. And at many institutions, gastric sleeves are now performed more commonly than the Roux-en-Y procedure for weight loss. What are some of the common complications of the gastric sleeve surgery?

Victoria Gomez:

The two most common complications that we tend to see are leaks and stenoses of the sleeve. Leaks can occur either proximally at the angle of His at the EG junction or can occur distally, but we tend to see them more proximally for multiple reasons. And sometimes you can see a leak in conjunction with a stenosis. Usually the stenoses that we talk about are the ones more distally at the incisura angularis, and it could be due to true obstruction, you know, if you truly cannot pass your scope through or the barium doesn't go through. Or it could be a functional stenosis as well. There could be torsion with how the sleeve was created intraoperatively. And a lot of times that can be picked up by a skilled bariatric endoscopist who has to, when you're going into the body of the stomach, instead of a nice smooth transition into the antrum, you have to do this big torque with your scope. That's not normal. Or the radiologist may comment on during the barium study that the barium sits in the proximal body until it empties into the antrum. So that should cue you in that there could be a functional stenosis present.

Speaker 2:

Great teaching points. And as you've mentioned earlier on for that type of surgery, they remove a large portion, 75, 80% of the stomach. And so some of these complications, you can see why they might develop. And so let's think about that patient then with sleeve stenosis. And as you mentioned, that's more likely to occur distally than proximally. How do you treat sleeve stenosis?

Victoria Gomez:

Some type of dilation is probably warranted. The literature is a little heterogeneous on algorithmic approach, but some may advocate to start with dilation with a hydrostatic balloon through the scope up to 20 millimeters. But if that doesn't work, you probably need to step up your game and use a pneumatic balloon dilator, what people use for achalasia. So you need a rigid achalasia balloon under fluoroscopy with a guide wire. And once you get to that area of stenosis, which again is usually at the incisura angularis, you park there and you blow up the balloon. We usually start at a minimum of 25 to 30 millimeters, and you wait there for a few minutes. And patients may need serial dilations. There are other interventions. There are prostheses such as stents, but at least in the United States, we currently don't have the proper stents for bariatric surgical complications. But in other countries, these are now being developed. But in summary, the dilation would be the mainstay treatment. However, if you were to detect a major torsion, something that is just not correcting itself endoscopically, then the patient is likely looking at a surgical revision.

Speaker 2:

And Victoria, I like the way you said that an awful lot, and for just to clarify that for our listeners, standard dilation first with balloon, a hydrostatic balloon, but then if they fail that, a pneumatic balloon. But I like the way you said that it should be under fluoroscopy, right? You should not be doing this blindly and then with a guide wire intact in place, right?

Victoria Gomez:

Absolutely. I mean, these are higher risk interventions, higher risk of adverse events. You want to make sure that your balloon is positioned properly. It could slip. Sometimes providers may think that they're dilating the incisura angularis when they may be dilating the pylorus. Dilating the pylorus to 30 millimeters is probably not the safest thing to do. So everything has to be done under the safest and the most well-regulated circumstances.

Speaker 2:

Wonderful. Let's keep our patients safe and let's keep our providers safe as well. So it's interesting you mentioned that theoretically, of course, a leak could occur anywhere along that big surgical resection, but they're a little bit more common proximally. What about treating these surgical leaks? Is that something we can do endoscopically, or do we have to send them all back to surgery? Or what do we do?

Victoria Gomez:

Like in any situation, the patient is showing signs of sepsis or severe sepsis, they need to go back to the operating room for surgical exploration. But if that is not the case, then fortunately, at least in the early period, many of these sleeve leaks can be managed endoscopically by bypassing the area of extravasation with a stent, a temporary stent. But sleeve leaks, let me just put this disclaimer out there. Sleeve leaks are, I would say, a different game. You're in a different ballpark when you deal with sleeve leaks because it depends on the timing of the leak and its chronicity. So early sleeve leaks, you know, you can bypass the defective area by placing a stent. If you see major stenosis at the incisura angularis, you can also perform a dilation there because keep in mind that a sleeve gastrectomy creates a tubularized stomach, so you have this column of pressure.

So if you have a stenosis at the incisura angularis, you're creating an upstream pressure, which is only going to continue to perpetuate this leak. And so you could bypass the leak until it heals on its own, but you need to make sure that downstream there isn't an obstruction or stenosis. Now for chronic leaks, this is where it gets more interesting, and it depends on the expertise of the center. It usually requires a multidisciplinary approach. For chronic leaks that are more than three months out may require something other than stenting. And that's when you start bringing into play double pigtail stents, septotomies to open up the defective area where the leak, which basically now becomes a fistula. You open it up, you dilate downstream everything to redirect that pressure gradient. And this can take many months. In severe circumstances where the defect is very large, it may require even endoscopic vacuum system, multiple exchanges, patients may require percutaneous drainage.

So it requires a multidisciplinary team approach with the endoscopists, the surgeons, the interventional radiologists. But again, to keep everyone levelheaded, the first and foremost important thing to address apart from containing the infection, is the patient's nutritional status. So when patients come in for management of leaks, doesn't matter at which stage, you have to make sure that you try and resume their enteral nutrition. You don't really want to start putting patients on TPN or intravenous nutrition unless absolutely needed. So whether you need to bypass that area of the leak or the fistula with a nasal enteric tube or whatever other means, but you want to maintain nutrition. It's very important.

Speaker 2:

Victoria, great description, and I really like the way you explained it in terms of a pressure and a pressure head. And so I think for our listeners, again, if you identify that proximal leak, don't just stop there. Think that maybe a distal stenosis could be a part of the problem. So you got to really attack both. That's great. Victoria, this has been a wonderful conversation. I can't thank you enough. Any last thoughts for our listeners?

Victoria Gomez:

As our population, as the prevalence of obesity increases in the United States and globally, that we will start seeing more and more patients that not only undergo bariatric surgery, but will have been already several years out from their operation. And it will be not only up to just gastroenterologists, but also primary care physicians who will be seeing these patients in the future. And the best thing to do is that when you're concerned about a possible complication after bariatric surgery, is to always have your patient taken care of in a center that specializes in this topic. So you really want to go somewhere where the patient can be seen in a multidisciplinary approach, by a weight management clinic, an endoscopist with experience, a good surgical team, radiology team, et cetera.

Speaker 2:

Wonderful. Victoria, thank you. For our listeners, you've been listening to Dr. Victoria Gomez, a Social Professor of Medicine and Director of the Bariatric Endoscopy Program at Mayo Clinic Jacksonville. Thank you so much for educating me, and thank you for educating our listeners. And for our listeners, we hope you turn into another Gastroenterology Learning Network podcast in the near future. Thanks so much.

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