The use of over-the-scope clip in the treatment of persistent staple line leak after re-sleeve gastrectomy: Review of the literature.

Staple line leak after sleeve gastrectomy (SG) is a severe complication associated with increased mortality rates and the potential need for reoperation. We report the successful management of a re-SG staple line leak with the use of an endoscopic over-the-scope clip.

INTRODUCTION

Staple line leak is one of the most serious post-operative complications of sleeve gastrectomy (SG) and can result in intra-abdominal abscesses and sepsis.[12] The incidence of the leak is 1%–2.7% and the respective leak associated mortality is 9%.[3] According to the algorithm for the treatment of post-operative leak after SG, therapeutic strategies range from conservative to non-operative treatments such as drainage, endoscopic stents, biological glues, clips or even revisional surgery in case of failure of conservative treatment.[24] However, the available data do not favour one treatment over another.[5] The endoscopic over-the-scope clip (OTSC) is a recently developed endoscopic method resulting in the full-thickness closure of the leakage site due to the enhanced ability of entrapping the tissue.

This report describes the successful management of a re-sleeve staple line leak with the use of OTSC.

CASE REPORT

A 40-year-old woman (body mass index 44.6) and a history of open SG 2 years earlier was submitted to a revisional open SG due to inadequate weight loss and concomitant incisional hernia repair. The post-operative course was prolonged due to fever and the patient was discharged on the 12th post-operative day. Shortly after discharge, the patient developed fever and abdominal pain, the clinical condition deteriorated and 7 days postoperatively she was admitted to a regional centre. An abdominal computed tomography (CT) scan with intravenous contrast medium revealed a collection measuring 127 mm × 95 mm × 90 mm with a fluid gas level. The patient was referred to our institution.

On admission, the patient had clinical signs of sepsis necessitating supportive conservative management. A percutaneous CT-guided drainage of the collection with an 18G needle with the placement of a 10F was performed. An upper gastrointestinal (UGI) gastrografin swallow study[2] depicted a leak near the gastroesophageal junction [Figure 1]. Seven days later, a new CT scan showed significant reduction of the collection (74 mm × 37 mm), whereas a left-sided pleural effusion developed. A UGI endoscopy revealed the presence of a 4–6 mm in diameter fistula located 30 mm below the gastroesophageal junction. Due to the fact that the leak persisted, as it was confirmed by a UGI study, a decision was made to apply the OTSC device. A 16.5 mm OTSC was then deployed with successful closure of the fistula orifice. Five days after the OTSC placement, a revisional CT scan revealed complete resolution of the encapsulated collection and elimination of the pleural effusion. Subsequently, additional imaging work up with revisional UGI and UGI endoscopy [Figure 2] confirmed the proper placement of the clip, the closure of the leak and the absence of a sleeve stricture. The patient returned to oral diet and the clinical condition ameliorated.

Figure 1

Upper gastrointestinal study showing a leak located near the gastroesophageal junction

Figure 2

Endoscopic view of the over-the-scope clip

The total hospitalisation stay was 65 days. During the follow-up, the patient continued to tolerate oral intake and remained asymptomatic.

DISCUSSION

Leaks after laparoscopic sleeve gastrectomy (LSG) are classified according to the timing of presentation as early, intermediate and late. By clinical relevance and extent of dissemination, they are characterised as Type I, II. Based on both clinical and radiological findings, Type A classification includes microperforations without clinical or radiographic evidence of leak, Type B represents leaks detected by radiological studies without any clinical finding, Type C leaks are both radiological and clinical apparent.[678] In our case, the patient presented with a late, Type II, Type C leak after re-sleeve.

Regarding the technique, successful closure, in this case, was accomplished using the Ovesco 11/6t 16.5 mm (Tubingen, Germany) OTSC. Using a single-channel endoscope-gastroscope (GIF-Q165, Olympus), the site of the leak was identified, and the margins of the lesion were debrided with argon. The endoscope was withdrawn and the OTSC was placed on the distal end. The clip consists of nitinol, a shape memory elastic alloy having the shape of a bear trap, mounted on a transparent plastic housing or cap attached to the tip of the endoscope. OTSC application mechanism is similar to that of variceal band ligation devices. A wheel attached onto the shaft of the endoscope is being turned, and at the same time, traction is applied on a thread passing through the endoscope's working channel that deploys the clip from the distal cap. The endoscope was re-inserted, and the site of perforation was centred within the cap of the OTSC followed by suctioning of the tissue into the cap. Subsequently, clip release and closure resulted in an approximation of perforation margins between the grasping teeth of the OTSC while the tissue was kept vital based on a predefined distance between the clip teeth promoting sufficient vascular perfusion.

OTSC is a novel endoscopic technique for the treatment of gastrointestinal defects.[9] Various reports demonstrate the efficacy of OTSC in demanding clinical conditions. Regarding leak after SG, OTSC demonstrated high rates of efficient closure. Keren et al. reported a success rate of 80.76% in a series of 26 patients undergoing clip application for staple line leakage (84.61%) and lower antral leaks (15.38%). However, the majority of leaks in which OTSC was applied were early or intermediate. Regarding late persistent leaks, the presence of fibrosis seems to have negative impact on the effectiveness of the OTSC.[1] The debridement of the scar tissue using the argon beam system is an essential step of the procedure. In addition, a retrospective study on the use of OTSC in digestive fistulas demonstrated higher efficacy rate (88.9%) in staple line fistulas after SG compared to other GI fistulas (61.1%).[10] Furthermore, the combined use of OTSC with mega stents in post-SG leaks has also been suggested with quite promising results.[7]

Collections and leaks after LSG rarely resolve without any kind of intervention or re-operation. In our case, reoperation was an option that increased the risk for post-operative complications due to the fact that the patient underwent re-sleeve and mesh placement. The application of an OTSC, as the primary therapy, mimicking a serosa to serosa suture resulted in the successful management of staple line leak after re-SG even for a late leak. Further studies are needed to confirm the efficacy of the OTSC clip as an alternative strategy in the management algorithm of leaks.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.