Page 92 - Read Online

Page 6 of 13 Castro et al. Mini-invasive Surg 2020;4:47 I http://dx.doi.org/10.20517/2574-1225.2020.14

Figure 2. Endoscopic view of the septotomy completed with the abscess cavity fully exposed to the gastric lumen. (a) Abscess cavity; (b)
gastric lumen

Common symptoms involve nausea, vomiting, abdominal pain, inadequate gain loss or weight regain,
dysphagia, dyspepsia, reflux, increased stools, among others [32,33] . Complications may present in the early
or late postoperative period. They can present as hemorrhage, leaks, fistulas, strictures, ulcers, or erosion
and their management will depend according to the type of complication. When the patients’ condition is
suitable, less invasive techniques are preferred. Many endoscopic procedures have been widely used over
the years; however, newer devices have been recently developed.

Leaks
One of the most feared complications of bariatric surgery is the development of gastric leaks and fistulas.
Even though leaks have a low incidence rate, their presentation causes a 2-fold increase in mortality and
[34]
a 6-fold increase in hospital stay . In RYGB patients, most leaks arise at the gastrojejunal anastomosis,
[35]
whereas in laparoscopic sleeve gastrectomy (LSG), they are usually found along the staple line and
at the gastroesophageal junction [36-38] . Leaks can be classified according to their time of presentation as
[39]
acute, early, late, or chronic; presenting < 1, 1-6, 6-12, > 12 weeks after surgery, respectively . Endoscopic
treatment with the use of stents, sealants, or clips has been broadly used in bariatric surgery with positive
outcomes described in the literature [40,41] . Of these, the most common used are stents. New and innovative
endoscopic procedures are now available and suppose a promising alternative.

Septotomy
Abscess septotomy is a procedure utilize to control late to chronic leaks, that consists in dividing the
septum formed between the abscess cavity and the gastric lumen. This allows for equalization of pressures
[37]
in both cavities, favoring the drainage of the abscess cavity into the sleeve lumen [Figure 2]. Ortega et al.
reported their experience with chronic leaks after LSG that were managed successfully with abscess
septotomy in combination with aggressive dilation of the sleeve and axis rectification in order to promote
distal drainage and improved management of the intraluminal pressures. Shnell et al. reported 10 patients
[39]
with late and chronic leaks that were also effectively managed with septotomy. The authors performed
on average 5 endoscopic sessions to completely resolve the leak. Nonetheless, two cases with a small
perigastric cavity (< 15 mm), only needed one session to achieve leak resolution. They consider several
sessions necessary to adequately drain the abscess cavity, as well as performing stricture dilation for better
outcomes. This procedure represents a safe, feasible, and less invasive approach that should be strongly
considered for the management of late and chronic postoperative leaks [42-45] . In our center, we prefer