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Endoscopy should be first fix for bariatric surgery complications
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ORLANDO — While endoscopic bariatric procedures for obesity treatment increase, one expert here addressed the need for endoscopy as first-line treatment for existing bariatric surgery complications.
“There are a variety of adverse events associated with [bariatric] surgery and endoscopy is often the first-line treatment, but it often requires multiple modalities and multiple procedures,” Reem Z. Sharaiha, MD, MSc, of Weill Cornell Medical College, said during a presentation in the Postgraduate Course held before the World Congress of Gastroenterology at ACG 2017. “Most complications are amenable to endoscopic therapy so we must know the post-surgical anatomy and the team approach is key.”
Sharaiha said complications leading to endoscopy can occur in up to 30% of patients who undergo bariatric surgery. Endoscopy should be the first option for treating these complications because surgical revision increases morbidity and mortality, she explained.
Anastomotic ulcerations, hemorrhage, anastomotic strictures, band erosion, leaks and weight regain are the most common complications seen after bariatric surgery, Sharaiha said.
Sharaiha reviewed presentation of these complications and the endoscopic techniques for treatment, which were recently included in a review published in Gastroenterology.
Leaks, she said, are most common.
“That’s really what we see and they are notoriously hard to treat,” Sharaiha said. She warned that leaks can lead to high levels of morbidity and mortality and endoscopists must keep in mind all possible sources of the leaks. Additionally, the time to closure for any leak is important, she said.
“For primary suturing, your success is significantly higher for fistulas and leaks, if it’s done within the first 30 days,” Sharaiha said.
Lastly, she addressed weight regain after gastric bypass. Sharaiha said this usually occurs 2 to 3 years post-operatively but surgical revision has a morbidity rate of 5% to 10%.
Using endoscopic sleeve plication for revision of sleeve gastrectomy, on the other hand, resulted in total body weight loss of 10%, Sharaiha said.
“Endoscopy should be the first line of treatment for complications,” she concluded. – by Katrina Altersitz
Reference: Sharaiha R. Postgraduate Course. Presented at: World Congress of Gastroenterology at American College of Gastroenterology Annual Scientific Meeting; Oct. 13-18, 2017; Orlando, FL.
Disclosures: Sharaiha reports receiving grant/research support from Apollo and acting as a consultant for Apollo and Boston Scientific.
Perspective
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Shelby Sullivan, MD
I agree with Dr. Shariah that endoscopy should be a first-line treatment for many post-bariatric surgery complications. Managing a postsurgical complication with surgery carries higher risk than initially trying an endoscopic procedure, and in many cases we are able to treat a large number of bariatric surgery complications with endoscopic therapy. Not all, but many postoperative Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy complications — even early complications like bleeding that occurs within 24 hours — can typically be treated endoscopically.
However, there are certainly some complications that have to be treated by surgery, including internal herniations, leaks that cause the patient to be unstable and need surgical drainage, and some cases in which we’re not able to heal a long-term chronic fistula. The key for gastroenterologists is to know which complications can be treated endoscopically, and which complications need to be treated surgically.
Once a patient has undergone bariatric surgery, performing an additional surgery is difficult and associated with higher morbidity and mortality. I think both endoscopists and surgeons alike would agree that treating complications endoscopically and preventing the need for re-operation is a good thing.
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