Using the StomaphyXTM Endoplicator to Treat a Gastric Bypass Complication.

2011·0.24 MB·English

by  deWolfe, Melissa A.

C R
ASE EPORT
Using the StomaphyXTM Endoplicator to Treat a
Gastric Bypass Complication
Melissa A. deWolfe, DO, Curtis E. Bower, MD
ABSTRACT INTRODUCTION
BackgroundandObjectives:Asthenumberofbariatric Obesityisbecominganincreasinglywidespreadepidemic
operations performed increases, the number of patients in the United States. According to a study performed
requiringreoperationforfailedweightlossisexpectedto between 1999 and 2004,1 the incidence of overweight
proportionately increase. Natural orifice surgery is an al- children and adolescents has increased from 13.9% in
ternative approach to revisional gastric bypass surgery 1999to2000to17.1%in2003to2004.Similarly,obesityin
when postoperative complications, such as dilatation of adultshasincreasedfrom30.5%to32.2%duringthesame
the gastrojejunostomy, gastrogastric fistula, and gastric
time period. As a result, the number of weight loss sur-
pouch, dilation occur.
geries being performed in the United States has predict-
ably increased from 13 365 in 1998 to more than 100 000
Methods: The present article reports on the safe and
successfuluseofanendoscopictissueplicatingdevicein in2003.Thisupwardtrendinbariatricsurgeryislikelyto
a patient found to have a dilated gastric pouch and a continue until the obesity epidemic is controlled. With
gastrogastric fistula 12 years after an open, nondivided this, bariatric surgeons are now encountering the chal-
RYGB. lenge of more and more patients who require revisional
procedures secondary to failed weight loss or complica-
Results: The procedure was performed without compli-
tions.
cations and resulted in a reduced pouch size to approxi-
mately 30cc to 50cc and redirection of the flow of gastric
Single institution case series2 indicate that revisions are
contents through her gastrojejunostomy. The patient’s
performedin5%to60%ofpatientswhohaveundergone
earlysatietyreturnedand,1yearpostoperatively,shehad
primary restrictive or restrictive-malabsorptive proce-
incurred a 45-pound weight loss.
dures. Approximately 10% to 40% of patients fail to
Discussion:Themorbidityandmortalityofrevisiongas- achievelong-termweightlossafterRoux-en-Ygastricby-
tric bypass was avoided while the patient’s goal of mod- pass (RYBG), usually secondary to dilation of the gastric
erate weight loss was achieved. Tissue plicating devices pouch, and less commonly to gastrogastric (GG) fistula.3
offer an alternative for repair of some postbariatric com- Both open and laparoscopic surgical revision procedures
plications. With the rapid advances in endoluminal tech- have been used for repair. However, surgical interven-
nologyandincreasingexperiencewithnaturalorificesur- tion can be challenging and fraught with serious mor-
gery, the ability to successfully address surgical problems bidities, even in the most experienced hands. Second-
through less invasive means will continue to improve. ary to factors like extensive intraabdominal adhesions,
ulcers, inflammation, bowel obstructions, and meta-
KeyWords:Bariatricsurgery,Complications,Fistula,En-
bolic disturbances leading to poor nutrition, revisional
doscopy.
surgery can lead to undesirable outcomes. These in-
clude leak, obstruction, perforation, staple-line disrup-
tion, blind loop syndrome, bleeding, stricture, sepsis,
wound dehiscence, pulmonary embolism, and death.4
NaturalorificesurgeryusingtheStomaphyXendoplica-
ECUDepartmentofSurgery,BrodySchoolofMedicine,Greenville,NorthCarolina, tor is an alternative approach to revisional gastric by-
USA(allauthors). pass surgery when postoperative complications occur.
Addresscorrespondenceto:CurtisE.Bower,MD,ECUDepartmentofSurgery,600 Its minimally invasive nature makes it a safe and prom-
MoyerBlvd,Greenville,NC27834,USA.Telephone:[phone],Fax:(252)
ising approach that may be associated with fewer intra-
744-3809,E-mail:[email protected]
operativeandpostoperativecomplications.Thefollow-
DOI:10.4293/108680811X13022985131570
ing case highlights the use of StomaphyX to restore
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. weight loss in a patient after nondivided RYGB.
JSLS(2011)15:109–113 109
UsingtheStomaphyXTMEndoplicatortoTreataGastricBypassComplication,deWolfeMAetal.
CASE REPORT history, it has also been laden with failed operations and
serious postoperative complications that require revision.
A 45-year-old white female presented 12 years after an
Because of the significantly higher perioperative compli-
open, nondivided RYGB. Over the preceding 6 months,
cationrate,theriskofrevisionalsurgerymustbebalanced
she no longer experienced early satiety and gained 40
against its potential benefit. The risk of developing peri-
pounds. An upper GI (UGI) revealed a dilated gastric
operativecomplicationsafterrevisionalbariatricsurgeryis
pouch and a GG fistula, which was confirmed on endos-
2to3timesgreater,andtheleakratemaybe5to10times
copy.Thepouchwasestimatedtobe150ccto200ccwith
higher. This is likely related to factors such as impaired
a 2-cm GG fistula. The gastrojejunal (GJ) stoma was also
tissue quality and markedly decreased blood supply in
dilated.
reoperative areas.5 Despite this, some authors advocate
Thepatientelectedtoproceedwithnaturalorificesurgery operativerevisionforfailedweightloss,becauseofeven-
using the StomaphyX device. The device did not allow tual improvement in comorbidities associated with obe-
placement of plications directly at the fistula site, but did sity.6
allowplacementoffull-thicknessfastenersinaconcentric
fashion from the GJ to the gastroesophageal junction. One study reviewed a prospective database of patients
Pouch size was reduced to approximately 30cc to 50cc. undergoing both primary and open revisional bariatric
AlthoughpostoperativeUGIshowedpersistentGGfistula, proceduresbetween1998and2007.Ofnote,inthisstudy
italsoshoweddelayedflowthroughtheGJandamarked inadequate weight loss alone was not viewed as an indi-
decrease in pouch size, which ultimately enabled the cationforrevision.A9-foldincreaseinleaks,a2-to5-fold
patient to achieve her desired outcome of weight loss. increase in ICU utilization, and a 1.5-fold increase in
lengthofstayinpatientsundergoingrevisionalcompared
At 2 months after surgery, the patient had regained early
with primary bariatric surgery was found. Despite this,
satiety and lost 25 pounds. Now, nearly 1 year after her
researchers had a 0% 30-day postoperative mortality rate
gastric pouch endoplication, she continues to experience
for revisions. They concluded that, in experienced hands
early satiety and has lost 45 pounds. We will continue to
and via the open approach, revisional bariatric surgery
followthispatientandrecordherprogress,asmorelong-
can be safe.2 Another case series reported on the out-
termdataarenecessarytoevaluatethetrueefficacyofthis
comes of 215 consecutive revisional bariatric operations
procedure (Figure 1).
performed by 1 surgeon over the past 22 years. All but 3
of these procedures were performed open. Weight loss
DISCUSSION
failure was the indication for 151 of these, and complica-
Although bariatric surgery can result in durable and sig- tions from the primary procedure were the indication for
nificant weight loss, throughout its approximate 50-year theother64.Researchersfoundmajorperioperativecom-
Figure1.Endoscopybefore(a)andafter(b)plicationusingtheStomaphyX.
110 JSLS(2011)15:109–113
plications in 45 patients (21%): 15 leaks, 11 wound infec- Mostrecently,areview10oftheinitialUSexperienceusing
tions, 3 pulmonary embolisms, and 16 miscellaneous, in- the StomaphyX device to decrease gastric pouch size in
cluding 3 deaths (1.4%). Complications were more patients undergoing RYBG concluded that endoluminal
frequent,occurring36.9%ofthetimeinpatientswhohad revision using the StomaphyX may offer a safe and effec-
had primary procedures performed by other surgeons, tivealternativetorevisionalbariatricsurgery.Theauthors
versus 10.3% of patients on whom the surgeon had per- usedtheStomaphyXtoperformendoluminalreductionof
formed the initial procedure. This led him to suggest that gastric pouches in 39 patients, over 90% of whom were
surgeons should perform their initial revisions on their female with an average age of 47.8 years and an average
own patients, rather than patients being referred from body mass index (BMI) of 39.8 kg/m2. At 2 weeks post-
other surgeons.5 procedure, patients had lost an average of 3.8kg (7.4%
excessbodyweightloss,EBWL).At6months,theremain-
Becausethenumberofoperationsperformedfortreating
ing patients being followed (n(cid:1)14) had lost 8.7kg (17%
morbid obesity has increased almost 10-fold during the
EBWL), and at 1 year, the 6 patients still being followed
past decade, the number of patients requiring bariatric
had lost 10kg (19.5% of EWBL). As with our patient,
revisionforfailedweightlossorcomplicationhaspropor-
symptoms improved, and no major complications oc-
tionately increased also. While most of these are per-
curred.
formed open, some laparoscopic revisions performed on
primary laparoscopic operations, show fewer wound Theabovestudiessuggestthatsomepostbariatriccompli-
complications, less blood loss, and lower mortality.6 cations can be successfully addressed using endoscopic
methods. Although several endoscopic examinations
With the advent of natural orifice surgery, the armamen-
were required, surgery and its associated complications
tarium of possibilities to treat patients with failed primary
were avoided. The procedures were tolerated well with
bariatric procedures has further broadened. Those most
minimal complications.4
likelytobenefitfromtheseprocedures,inadditiontothe
morbidlyobese,includethecriticallyillandthoseathigh
Our case report demonstrates that the StomaphyX is an-
risk for surgery because of significant comorbidities.7 A
otherdevicethatwarrantsconsiderationinpatientsfailing
case series of 3 patients with chronic gastric leaks after
to achieve satisfactory weight loss after RYGB. With fur-
RYGB showed successful leak closure using a variety of
ther study, and more long-term data, the efficacy of this
endoscopicmethods.Theseincludedargonplasmacoag-
procedure will be better elucidated. We have had diffi-
ulation, hemoclips, fibrin glue, Polyflex stent placement,
cultyrecruitingpatientsforStomaphyXendoluminalrevi-
anddistalGJstenosisdilation.Inallpatients,leakclosure
sion at our institution, because the procedure is not cov-
was achieved and symptoms resolved completely. The
ered by insurance, and the majority of our patients are
onlycomplicationwasstentmigrationinonepatient,and
Medicare or Medicaid insured. Despite this, we suggest
it was retrieved endoscopically.4 In addition, a retrospec-
that all postbariatric surgery patients with nonlife-threat-
tive analysis8 looked at treating 19 patients after various
eningcomplications,suchasdilatedgastricpouch,dilated
bariatricprocedures(11withleaks,2withchronicfistulas,
GJ anastomosis, and GG fistula be considered for endo-
and 6 with strictures) with endoscopic stent placement.
luminal repair using StomaphyX. Exclusion criteria for
Oral feeding was started immediately in 79% of patients.
endoluminalrevisionshouldincludethepresenceofperi-
At mean follow-up of 3.6 months, 90% had symptomatic
toneal signs or a free perforation and leak into the peri-
improvement and 84% had resolution of leak or stricture.
toneal space, both of which require emergent operative
Healingoccurredatameanof33daysforleak,46daysfor
repair.
fistula,and7daysforstricture.Stentmigrationoccurredin
58% of stents placed, with 3 requiring surgical removal. The StomaphyX is a transoral device that places full-
Another case series9 of 8 patients with significant weight thickness polypropylene SerosaFuse fasteners, creating
regain and dilated GJ anastomosis after RYGB demon- gastric plications. These fasteners are nonabsorbable and
strated the effectiveness of endoscopically placed sutures havestrengthequivalenttoa3-0suture.Throughtension-
at the rim of the GJ anastomosis. When tightened, these free tissue approximation, they can be used to shrink
sutures created tissue plications that reduced the anasto- stoma and gastric pouch sizes. There have been several
moticsize.At4months,6ofthe8patientshadlostweight casestudiesinwhichthedevicewassuccessfullyusedfor
(averageof10kg),andtheirBMIswentfromanaverageof pouch and anastomosis volume reduction. A case report
40.5 to 37.7. All endoscopic pouch reductions were done of2patientshasalsoshownStomaphyXtobeeffectivein
without significant complication. treating gastric leaks after RYGB.3 We attempted to ad-
JSLS(2011)15:109–113 111
UsingtheStomaphyXTMEndoplicatortoTreataGastricBypassComplication,deWolfeMAetal.
dress our patient’s gastrogastric fistula using the device diet,whichwasadvancedtoaregulardietwithinthenext
(Figure 2). couple of days. The morbidity and mortality of revision
gastric bypass was avoided while the patient’s goal of
One potential drawback of the device is that its overall
moderate weight loss was achieved (Figure 3).
structure and tip length somewhat limit the operator’s
ability to manipulate it. As a result, we were unable to
place fasteners in the location necessary to completely
CONCLUSION
closethegastrogastricfistula.However,thedilatedgastric
pouch and GJ stoma were successfully reduced. As a The StomaphyX is an alternative for repair of some post-
result, the restrictive portion of the patient’s initial proce- bariatric complications. In this case, although the gastro-
dure was recreated. Her early satiety returned and she gastricfistularemainedpatent,boththepouchsizeandGJ
began, and continues, to lose weight. In addition, the stoma were reduced, allowing the patient to again expe-
procedurewasfast(lastingapproximatelyonehour),well rience early satiety. She, therefore, continues to lose
tolerated, and without complication. The patient went weight by restrictive means. With the rapid advances of
homethefollowingmorningaftertoleratingaclearliquid endoluminal technology and increasing experience with
Figure2.(a)Tissueisdrawnintothechamber,and(b)plicationsarecreatedwhenthefastenersaredeployed.
Figure3.StomaphyX(a)Deviceand(b)tip.
112 JSLS(2011)15:109–113
natural orifice surgery, the ability to successfully address 6. Brolin RE, Cody RP. Impact of technological advances on
surgical problems through less-invasive means will con- complicationsofrevisionalbariatricoperations.JAmCollSurg.
tinuetoimprove.11Futureresearchmustfocusnotonlyon 2008;206:1137–1144.
the technological development of these devices, but also 7. Wagh MS, Thompson CC. Surgery insight: natural orifice
on their long-term safety, efficacy, and durability, com- transluminal endoscopic surgery- an analysis of work to date.
paredwithsurgicalalternatives,astheyareappliedinthe GastroenterolHepatol.2007;4:386–392.
clinical setting.
8. Eubanks S, Edwards CA, Fearing NM, et al. Use of endo-
scopic stents to treat anastomotic complications after bariatric
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