1. Advanced Endoscopy Techniques Jayant P.Talreja, M.D. Gastrointestinal Specialists, Inc. Bon Secours St. Mary’s Hospital

2. Case Presentation EGD 5/22/13: Previously placed Aponos clip in place No evidence of contrast extravasation Entire gastric pouch filled with contrast

3. Case Presentation EGD 5/22/13: What would you do next?

4. Case Presentation EGD 5/22/13: Empiric placement of a fully covered esophageal stent across site of suspected leakage. Stent secured in position with 4 hemoclips at proximal end. Limited contrast injection confirmed proper stent placement

5. Case Presentation Outlet obstruction symptoms after stent placement Outlet obstruction symptoms after stent placement Upper GI series 5/24 Upper GI series 5/24 Distal migration of the esophageal stent with minimal passage of contrast into the stomach and duodenum. Distal migration of the esophageal stent with minimal passage of contrast into the stomach and duodenum. Distal outlet of stent appears impacted against stomach wall causing partial obstruction Distal outlet of stent appears impacted against stomach wall causing partial obstruction

6. Case Presentation EGD 5/24/13: Previously placed esophageal stent was seen and removed. Previously placed Aponos clip was seen and was in same position. Contrast extravasation was seen and site of suspected leakage was identified. Three hemoclips were placed at that site. Following clip placement, contrast was injected and air insufflated. No extravasation was seen.

7. Case Presentation UGI Series 5/28 Persistent fistula just inferior to endoclip

8. Case Discussion What is a sleeve gastrectomy?

9. Case Discussion What is a sleeve gastrectomy?

10. Case Discussion Sleeve gastrectomy was initially devised to constitute the first stage of bariatric surgery for the super-obese or high risk patient Intention was to achieve significant weight loss that would reduce the peri-operative risks prior to more extensive surgery Is now being performed as a sole procedure for obese and super-obese Concept is to minimize the capacity of the stomach by resection Early satiety is caused by alterations in hormonal levels, impaired motility of remaining stomach, and/or elevated pressure within the sleeve

11. Case Discussion Sleeve gastrectomy can be associated with significant morbidity and staple line failure with dehiscence Gastric leak is one of the most severe complications Type I leak (subclinical local leakage) or Type II (clinically significant) Classified based on timing of appearance after surgery – early (1-3 days), intermediate (4-7 days), and late (>7 days).

12. Case Discussion Burgos et al. in 2008 sought out to study the clinical presentation, post-operative course, and treatment of gastric leak after sleeve gastrectomy for obesity October 2005 – August 2008, 214 patients with different degrees of obesity underwent sleeve gastrectomy During surgery, each patient received saline with methylene blue by way of a NG tube and had a drain placed. All patients underwent UGI series on POD 3

13. Case Discussion Seven patients developed a gastric leak (3%) Leak in 2 patients was diagnosed by UGI series on POD 3, remaining 5 presented at POD 5 or greater Two patients had a type I leak (28.6%) and 5 patients had a type II leak (71.4%) Leak located at proximal third in 6 (85%) and distal third in 1 (15%) Four patients underwent re-operation. Three patients were managed medically with enteral/parenteral feeding and drain maintained in-situ Mean length of stay 28.8 days, time to leakage closure 43 days

16. Case Discussion Endoscopic Management of Bariatric leaks Leak source must be localized – bubble test with CO2 insufflation Methylene blue with contrast into the drain If leak in proximal pouch, a stent is likely optimal therapy If leak is in a recessed area, stent will not be effective – clips, sealants, or suturing should be considered

17. Case Discussion Meta-analysis of 7 studies of stent placement (SEMS and SEPS) for treatment of acute leak after bariatric surgery Found a pooled proportion for radiographic evidence of leak closure after stent removal of 87.8% Duration of stent therapy was between 4 and 8 weeks in most cases Only 9% proceeded to revision surgery Pooled proportion of stent migration was 16.9% Stent placement after sleeve gastrectomy has been shown to be effective in small case series Gastrointest Endosc 2012;75(2):287-93 Obes Surg 2011;21(8):1232-7 Obes Surg 2010;20(9):1289-92

18. Case Discussion Endoscopic clips have also been used to close leaks Clips are used to approximate the tissue surrounding the defect to effect closure The clip should be deployed perpendicular to the long axis of the defect Multiple clips can be placed starting at either edge and meeting at the middle Over the scope clips can perform full thickness apposition

19. Efficacy of Endoscopic Closure of Acute Perforations of the GI tract prospective, international, multi-center study of 36 consecutive patients Acute iatrogenic perforations (5 esophageal, 6 gastric, 12 duodenal, 13 colonic) Used an over the scope clip (Ovesco Endoscopy AG, Germany) Bear trap like design, wingspan of 12 mm Designed to create a full thickness closure of perforations up to 3 cm in diameter Case Discussion Voermans et al. CGH 2012

20. Primary endpoint was successful closure (determined by water soluble fluoro analysis) and absence of adverse events within 30 days after the procedure. Immediate closure successful in 33 patients (92%) None of these patients had leakage on contrast x-ray One patient developed esophageal perforation with cap introduction Two patients’ perforations did not close despite clip deployment These 3 patients were treated successfully with surgery One patient with successful colonic perforation closure deteriorated clinically 6 hours later. Immediate laparotomy revealed clip detachment. Despite surgery, this patient died 36 hours later Case Discussion Voermans et al. CGH 2012

21. Overall success rate was 89% (95% CI, 75-96%) Mean endoscopic closure time was 5 min 44 sec +/- 4 min 15 sec 32 patients (89%) had successful closures without adverse events Regarding duodenal perforations – immediate closure unsuccessful in 2 patients 9 duodenal perforations were successfully closed (75%) 28/32 were available for follow up at 6 months (4 deaths, unrelated causes) 19 (79%) still had clip in-situ on surveillance imaging. Case Discussion Voermans et al. CGH 2012

22. Case Discussion Voermans et al. CGH 2012

23. Case Discussion

24. Case Presentation Three endoscopic procedures and patient still had persistent leak Three endoscopic procedures and patient still had persistent leak How many times should we try? How many times should we try? Should we be placing stents? Should we be placing stents? Is early surgery vs non-endoscopic conservative management better than endoscopic management Is early surgery vs non-endoscopic conservative management better than endoscopic management Initial leak was identified on 4/27/13 (POD 5) Initial leak was identified on 4/27/13 (POD 5) First endoscopic procedure was 5/20/13 First endoscopic procedure was 5/20/13

25. Questions?