The Post-stent Prodrome: Considerations and Utility of Endoscopic Stenting in the Management of Laparoscopic Sleeve Gastrectomy Leaks

Anirban Gupta, MD, FRCSC, Azam Qureshi, MD, Jenny Choi, MD, Abraham Krikhely, MD, Sammy Ho, MD, Pratibha Vemulapalli, MD, FACS, Diego Camacho, MD, FACS

Montefiore Medical Center

Introduction: There is increasing enthusiasm for the use of endoscopic stenting as a treatment modality for managing laparoscopic sleeve gastrectomy (LSG) leaks. In an era of increasing adherence to evidence based medicine, the literature in this regards is equivocal. We present and analyze a case report and review the current literature. We describe the “Post-Stent Prodrome” – the unique considerations, course and sequelae that a surgeon may encounter when using stents for LSG leaks.

Methods: A 34 year old diabetic male with a BMI of 37.8 underwent a LSG at our institution and presented with a proximal leak on the 2nd post-operative day. After initial reoperation for sepsis control which included washout, J-tube construction and drainage, our patient received his initial stent on the 4th post-operative day. In total, he received a total of 4 different stents over 3 separate endoscopic interventions during his hospitalization. He underwent pneumatic dilatation of the angularis incisura during the 2nd endoscopic intervention. We reviewed 18 publications that specifically report the use of stents for LSG leaks, and compared our experience with the literature.

Results: The stents migrated proximally on 2 occasions. Our patient experienced significant chest discomfort and reflux for the duration of the stents. After 60 days our patient’s fistula healed and he was tolerating a liquid diet, his stents were removed and he was discharged home in good disposition. When reviewing the literature, we found that 3 of the 18 publications were not appropriate for comparison. This left us with a pool of 110 LSG leaks. 58 of these patients received stents at varying times in their disease course. 25 of the 58 stented patients experienced complications. Range for time to healing was quite disparate and variable; 14-240 days for stented patients. Range for time to healing for non-stented patients was 7-91 days.

Conclusions: Stenting requires a skilled and available endoscopist, often warranting repeated interventions. The exact cause-effect relationship between stenting and healing is difficult to establish. As such, stenting may require other treatment adjuncts such as dilatation, as in our patient, who appeared to have a very tight angularis, which may have caused a functional distal obstruction . Stenting requires judicious serial clinical and radiographic evaluation. Stenting does not replace the basic surgical principals of fistula management and sepsis control. It is unclear if LSG leaks may heal despite the introduction of stents. Stenting is not a static “fix it and forget it” procedure but rather part of a dynamic ongoing evaluation and management strategy requiring close scrutiny and follow up – the “Post-Stent Prodrome”.

Session: Poster Presentation

Program Number: P456