Endoscopic approach for post-ruan-eye gastric bypass leaks, how to choose the best tool for each test. Obesity is considered a public health issue worldwide with associated comorbidities. Bariatric surgery remains the most effective and durable therapy. Ruan-eye gastric bypass is still considered the gold standard procedure. Although safe, leaks may occur in 0.5% to 1.5% of patients. Treating this condition is challenging and a multidisciplinary approach, including endoscopic intervention, is key to success. Selecting the best endoscopic approach depends on several factors, such as leak time, defect, size and location, device availability, patient acceptance and local experience. This video discusses the possible endoscopic approach to manage post-ruan-eye gastric bypass leaks, including advantages, disadvantages and mechanism of action for each approach. This is the case of a 50-year-old man with class 2 obesity. He underwent a revision of laparoscopic ruan-eye gastric bypass. In the end, an operative and EGD was performed. The gastrointestinal anastomosis had no signs of leaks, and an azolentary feeding tube was placed. In the 8th post-operative day, the patient presented abdominal pain. The upper GI series revealed a leak in the anastomosis. So, an azolentary feeding tube was placed and antibiotics initiated. The treatment of this condition must be guided by four pivotal points. The first one, systemic treatment with antibiotics, fluids and nutrition. The second, drainage if associated collection. After this, treatment of factors related to the leak and then defect repair. Two days later, the patient presented no improvement and a CT scan was performed. It is possible to see a leak and associated collection. Then, upper digestive endoscopy was indicated for evaluation and management. The endoscopy was performed using underwater technique with low CO2 insufflation to avoid collection disruption. You can see the anazolentary feeding tube placed in the alimentary limb and the leak orifice in the anastomosis with poor drainage. In this image, it is possible to identify the blind alimentary limbs, the anastomosis and the leak orifice. The fluoroscopy evaluation demonstrated a contained collection close to the pouch. The treatment options for this case included endoscopic closure and covering techniques associated with external drainage. However, we can also perform internal endoscopic drainage techniques with no need for external drainage, including pig tail stents and EVT, alone or combined. In this slide, we show the advantages and disadvantages of each procedure. Other endoscopic therapies include tissue sealants and glues, which cannot be used as there is no fissilose tract, cardiac septal defect occluder, not indicated because the absence of an epithelial tract, and endoscopic drainage with septotomy, but there was no sept at this point. We used the endoscopic internal drainage with two double pig tail stents, which are placed after proper positioning of the guide wire. Also, we associated the intraluminal endoscopic vacuum therapy using the triple lumen tube, allowing both drainage and nutrition with just one tube placed by the nurse. And this was the fluoroscopy evaluation. When there is an undrained collection, you need to have external or internal drainage, such as pig tail stents or intracavitary EVT. Intracavitary EVT was not possible due to the retroflexed position. We used the retro pig tail stents, as they are more flexible and softer than the conventional pig tails. Also, we associated an intraluminal EVT. We call this a bridge therapy, because it can increase the double pig tail efficacy and allow for drainage and nutrition. Remembering the four pivotal steps, at this time we have already done the systemic treatment and drainage, and the follow-up is the advanced endoscopic endoscopic treatment. Remembering the four pivotal steps, at this time we have already done the systemic treatment and drainage, and the follow-up stayed very well, being released oral intake. Six days after the first EGD, another EGD was performed. Again, we used the underwater technique, and now the opening of the proximal staple line is seen, associated with a septum in the middle of the image. This picture clearly shows the connection of the previous drainage collection with the pouch. The fluoroscopic evaluation confirmed the septum. This was an unexpected finding, but also reiterates an important benefit of the triple lumen EVT, because it avoided leakage to the cavity and promoted granulation tissue formation. As there was a septum, septotomy was performed. As there was a septum, septotomy was performed. We used the IT knife, and the procedure went well, with no complications. Then, we removed the stents and performed a mostasis with argon plasma coagulation. This was the final image. The cavity and the pouch were then just one compartment. Again, a modified intraluminal EVT was placed to prove healing. As learning points, septotomy must always be performed when a septum is identified. In this case, we transformed the pouch and the associated collection into just one compartment. We removed the double pigtail stent and placed an intraluminal EVT to reduce the risk of dehazens and accelerate healing. In this case, we could also use a conservative treatment or a self-expandable metal stent. However, we were afraid to worse clinical condition and allow stent migration. At this point, we have done three of the four pivotal steps and were expecting the defect to close. The patient is still very well. He was receiving PPI and oral supraphen. Seven days after the second EGD, the third was performed. The cavity was cleaned with hydrogen peroxide lavage. This is the place of the sebum, the jejunal limbs, and there was a normal rune-like gastric bypass anatomy. So, we removed the sutures as they represent foreign bodies. Here, the final endoscopic appearance is seen, representing a regular anatomy seen after a gastric bypass. And the final fluoroscopy was performed. In this case, the gastric bypass was removed. And the final fluoroscopy evaluation. The teaching points of these last procedures are that intraluminal EVT promoted granulation tissue and the removal of foreign bodies facilitates tissue healing. Finally, we finished the four pivotal steps. In the following, the patient did very well and had a hospital discharge. In conclusion, following the four pivotal principles for the treatment of gastric bypass, following the four pivotal principles for the treatment of post-bariatric surgical leaks, endoscopic therapies are now considered the gold standard method for stable patients. We need to know the mechanism of action of each endoscopic approach we take. Frequently, more than one endoscopic intervention is required. Always consider availability, personal and local experience, cause, and patient's preference. Close follow-up is essential. And finally, leaks after bariatric surgery is a complex condition and require a multidisciplinary management.

endoscopic approach

leaks

Roux-en-Y gastric bypass surgery

bariatric surgery

multidisciplinary approach