In Western countries, the surgical management of obesity has greatly expanded, and anastomotic leakage has been identified as an important prognostic indicator. Anastomotic leakage occurs in up to 9% of patients who undergo bariatric surgical procedures,¹ and reoperation is associated with substantial morbidity and a mortality rate of up to 14.7%.^2–4 In addition to doubling the risk of mortality, leakage results in a 6-fold increase in the length of the hospital stay due to wound infection, sepsis, respiratory failure, renal failure, thromboembolism, internal hernia, and small bowel obstruction.^2,5

In Asian countries, the prevalence of gastric cancer remains high, and gastric cancer is one of the most common cancers of the digestive system.⁶ The prognosis of stomach cancer continues to improve due to advances in surgical techniques; however, intra-abdominal anastomotic leakage continues to be one of the most serious complications following gastrectomy and causes increased mortality. The incidence of anastomotic leakage after gastric cancer surgery is as high as 20%, and the associated mortality rate may reach 80%, depending on the site and the size of the leakage.^7,8

The treatment options for postoperative leakage include conservative treatment with or without external drainage, endoscopic treatment with or without external drainage, and surgery. Although surgery has been the mainstay of therapy in patients with gastrointestinal leakage, fistula, and perforations, the most effective way to manage these complications remains a matter of debate. In patients with sepsis, surgical management is often required. However, a surgical intervention for postoperative leakage may be difficult, because surgical revision is associated with a high risk of mortality and morbidity.^9–11 In recent years, there has been increasing interest in the endoscopic management of postoperative leakage with the technical and instrumental development of endoscopic procedures to avoid the safety concerns associated with traditional surgical interventions. Lee et al¹² chronologically analyzed the clinical impacts of introducing endoscopic treatment. In a comparison of two groups—before and after the introduction of endoscopic treatment—there were differences in the length of the hospital stay (median, 32 days vs 27 days; P = 0.048) and the duration of antibiotic use (median, 28 days vs 20 days; P = 0.013). These results indicate that endoscopic management for appropriately selected cases can reduce the duration of hospital day and antibiotic administration in the treatment of anastomotic leakage. This article presents a review of the literature on treating leakage after gastrectomy or gastric bypass surgery, with a focus on endoscopic treatment.

Leakage is defined as a discontinuity of tissue apposition in the immediate postoperative period, which develops when the intraluminal pressure exceeds the tissue or suture line resistance.

Clinical suspicion is critical for an early diagnosis of leakage, especially after surgery. In the postoperative period, anastomotic dehiscence should always be considered whenever there is any deterioration of patients’ clinical condition, including the development of fever, respiratory failure, new changes on chest radiography, and multiorgan failure.¹³ The most common reported symptom of leakage is tachycardia, which is present in 72% to 92% of patients.^4,14 Nevertheless, studies have also reported nausea and vomiting (81%), fever (62%), and leukocytosis (48%), and a high suspicion for leakage is necessary for patients with any of these symptoms. Objective signs include increased drain output, as well as C-reactive protein levels above 22.9 mg/dL 2 days after surgery (sensitivity, 1.00).¹⁵

The diagnosis can be established using a combination of radiological and endoscopic imaging. Upper gastrointestinal series with water-soluble contrast and computed tomography (CT) have limited sensitivity because of the body habitus, but show high positive predictive values.^16–19 An endoscopic diagnosis of gastrointestinal leakage requires a careful examination of the esophagus, stomach, small bowel, colon, gastric pouch, and anastomosis site.

To increase the diagnostic yield, an endoscopic examination under fluoroscopy by using a combination of maneuvers, including a bubble test (submerging the drain while performing endoscopic insufflation; with bubbles indicating the presence of leakage), and an injection of contrast with methylene blue into an abdominal drain while observing endoscopically and fluoroscopically can be used to find evidence of leakage.² Repeated oral contrast examination, a CT scan, or an endoscopic examination is needed for patients with a high index of suspicion.

Many articles on endoscopic treatment have shown promising results. Lee et al²⁰ reported that endoscopic treatment was feasible for anastomotic leakage after surgery for cancer, with 95% technical success and 100% clinical success rates. Among 20 patients who underwent endoscopic treatment, the endoscopic technique consisted of hemoclips alone in four cases, glue alone in two cases, clips and glue in 12 cases, and clips and a detachable snare in two cases. On average, 1.1 ± 0.3 attempts were required to seal the leakage. The amount of fibrin glue varied from 2 to 4 mL, and the mean amount used was 2.6 ± 0.84 mL. The number of hemoclips used per treatment ranged from 1 to 6 (mean, 3.4 ± 1.46). In a prospective study of the endoscopic management of anastomotic complications from bariatric surgery, Bège et al²¹ reported a 100% technical success rate using wound clips and glue to close the residual or initial opening, with a mean of 4.4 endoscopies per patient, and neither mortality nor severe morbidity occurred. In many other studies showing the feasibility of endoscopic treatment, leakages and fistulas could be closed with sealants, hemoclips, or stents.^13,22–25 Vacuum-assisted drainage has recently been investigated, showing good results.²⁶ These techniques have been used in combination for the management of leakage and other types of fistulas.

Sealants

Fibrin sealant is a biodegradable compound with a long and varied history of surgical use. Anastomotic leakage can be treated successfully by endoscopic means using fibrin either alone or in combination with Vicryl mesh to seal the leakage. This technique, first described by Pross et al,²⁷ serves as an alternative to surgery or conservative treatment. Truong et al²⁸ adopted this technique, and they successfully treated seven of nine patients. Once the target mucosa has been excoriated, fibrin can be applied and a plug then forms. In some cases, multiple sessions may be needed for this method. A randomized trial by Hwang and Chen²⁹ found that in 13 patients with persistent enterocutaneous fistulas after 2 to 4 weeks of conservative therapy, the closure time was 4 days in the patients using fibrin glue versus 13 days in the control group. A previous case series of 52 patients with gastrointestinal fistula showed that endoscopic therapy was successful in 55.7% (n = 29) and, among them, 36.5% (n = 19) were cured with fibrin glue as the sole endoscopic management.²⁵ Lee et al³⁰ reported three cases of gastrointestinal fistula successfully treated with solely endoscopic injection of a tissue adhesive (Histoacryl^®) without specific complications. Curative treatment through a glue injection was more frequently performed in low-output fistulas than in high-output fistulas.

Hemoclips

Hemoclips are successfully used for the closure of perforations varying from a few millimeters to 2 cm, while in larger perforations, multiple clips during two or three separate sessions could be needed.²² The clip should be deployed perpendicular to the long axis of the defect, and in most cases, experience and technical effort are necessary. Both fresh perforations and chronic fistulas that have lasted for several weeks can be closed with clips.^31,32 Fresh perforations can usually heal quickly with clip closure alone, whereas 2 to 3 weeks may be required for the successful closure of fistulas.³³ Debridement or drainage of the infection before closing the defect is often needed because clips may tear through edematous tissue, causing closure to fail.²³ The use of rotatable clips or a cap-fitted endoscope can be useful for closing defects in the esophagus, especially if an en-face approach to the defect is unsuccessful.³⁴ Luminal distention and insufflation should be minimized before and after the procedure.

Stent placement allows leakage to be healed and often enables enteral nutrition, thereby potentially accelerating recovery and avoiding the need for parenteral nutrition.² Both covered self-expanding metal stents (SEMS) and self-expanding plastic stents (SEPS) can be used according to the site and size of leakage. Stent placement is performed after guidewire insertion using a forward-viewing endoscope with or without fluoroscopic guidance. The inserted stents are usually left in place for 2 to 8 weeks, because longer indwelling periods can increase the difficulty of extraction. SEPS are more easily removed than SEMS, but the migration risk is higher. A large-diameter SEPS can be placed inside the SEMS to induce pressure necrosis of the ingrown tissue; the stents can then be removed together a few days later.³⁵ After stent insertion, too early oral intake can induce bowel peristalsis, which can make the stent move; therefore, delayed oral intake is recommended to decrease the risk of stent migration. To reduce the migration of SEMS in anastomotic leakage, fully covered SEMS placement with a silk thread can be considered as an effective and safe treatment option.³⁶

Vacuum-assisted sponge closure consists of an open-cell sponge attached to external vacuum suction via a tube.³⁷ For this technique, polyurethane sponges are endoscopically inserted into the abscess cavity that is made by the leakage or into a large leakage, followed by the application of controlled continuous negative pressure. A transnasal tube is connected to the sponge for the application of an external vacuum.³⁸ The sponge stimulates the formation of granulation tissue, while vacuum suction improves perfusion, removes secretions, and drains the infected fluid. Recent initial reports have shown good results for this endoscopy-based vacuum therapy in the treatment of rectal anastomotic leakage after resection of the rectum.^39,40 Based on these results, this technique was applied in leakage from esophageal anastomoses.^26,38,41 A sponge that is cut to a size smaller than the wound cavity is fixed to the tip of the tube with a suture and is pushed into the fistula using endoscopic forceps (Fig. 1). The feeding tube is then attached to continuous vacuum suction and the sponge is changed 2 or 3 times weekly.⁴¹ The use of endoscopy-based vacuum therapy has recently been expanded to post-gastrectomy anastomotic leakage, for which it showed better results than those of SEMS.^42,43 A recent multicenter retrospective study demonstrated that the clinical success rate was 70.6%, and no deaths were caused by endoscopy-based vacuum therapy itself.⁴⁴

Figure 1. Vacuum-assisted sponge closure. (A) Ivor Lewis operation with esophago-gastrostomy site. (B) An approximately 1.2-cm fistula opening was identified below the esophagogastrostomy site. (C) Vacuum-assisted sponge closure was applied. (D) The fistula opening was successfully cured after 8 days of vacuum-assisted sponge closure.

Endoscopic suturing techniques have been demonstrated to be effective in fistula closure; however, device limitations combined with procedural complexity and the need for specialized technical skills have limited their adoption.² The StomaphyX suturing system (EndoGastric Solutions, Redmond, WA, USA) has been used to resolve gastric leakage.⁴⁵ Fernandez-Esparrach et al⁴⁶ examined sutured gastrogastric fistula repair using the EndoCinch suturing system. In their report, the initial success rate was 95% and the durable success rate was 35%.

Several reports have described gastric leakage closure using a cardiac septal occluder.^47–49 A cardiac septal occluder is a self-expandable double-umbrella–shaped polyester-covered nitinol wire mesh. A delivery catheter is inserted over a guidewire placed through the leakage, then the guidewire is removed and the deployment catheter (preloaded with the cardiac septal occluder) is inserted through the delivery catheter. The endoscopist can deploy a cardiac septal occluder under endoscopic and fluoroscopic visualization. However, this device has a high risk of migration due to the lack of epithelialization, so it should only be used in salvage therapy.⁴⁸

The management of patients with postoperative leakage can be challenging. A novel algorithm is proposed to help understand the diagnosis and treatment of postoperative anastomotic leakages (Fig. 2). Surgical management can be associated with high morbidity and mortality; therefore, the initial management should focus on alternative methods, such as endoscopic procedures, to avoid reoperation. Endoscopic management for postoperative leakage can thus be considered a good treatment option for properly selected patients.

Figure 2. Proposed algorithm for the diagnosis and treatment of postoperative anastomotic leakage. SIRS, systemic inflammatory response syndrome; GI, gastrointestinal; CT, computed tomography.

None.

No potential conflict of interest relevant to this article was reported.