Editorial
Therapeutic flexible endoscopy after bariatric surgery: a solution for complex clinical situations
Endoscopia flexible terapéutica tras cirugía bariátrica: una solución a situaciones clínicas complejas
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=> array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Manoel Galvão Neto, Josemberg Marins Campos" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Manoel" "apellidos" => "Galvão Neto" "email" => array:1 [ 0 => "Galvaon@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Josemberg" "apellidos" => "Marins Campos" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Gastro Obeso Center, São Paulo, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Investigational Surgical and Endoscopic Procedures Committee, International Federation of the Surgery of Obesity (IFSO), Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sociedad Brasileña de Cirugía Bariátrica y Metabólica, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidade Federal de Pernambuco, Pernambuco, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Endoscopia flexible terapéutica tras cirugía bariátrica: una solución a situaciones clínicas complejas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The inter-relationship of advanced therapeutic endoscopy and bariatric surgery makes it easier to manage postoperative complications with a minimally invasive approach while avoiding complex reoperations that could increase morbidity and mortality. For these reasons, endoscopy after bariatric surgery can be used in surgical situations that are difficult to manage, such as: infection/fistula, weight regain, choledocholithiasis, stenosis and complications associated with the gastric band.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This technique is becoming more frequently used and could be considered an endoscopic surgery subspecialty based on the growing number of publications.</p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fistulas of the gastric bypass pouch and after gastric sleeve procedures</span> can cause peritonitis or perigastric abscess, which would need reoperation in the first case or a conservative approach in stable patients treated with abdominal drainage. This type of abscess can be treated without surgery by means of trans-abdominal percutaneous drainage or internal endoscopic drainage, which represents a lower risk of injury to adjacent organs.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Endoscopic therapy can be used in conjunction with surgical treatment mainly in early postoperative stages, and even during reoperation, with the intention to resolve the 3 main mechanisms that maintain the fistula: (1) distal gastric stenosis; (2) intragastric hypertension; and (3) persistence of the fistulous tract. These principles can be applied to Roux-en-Y bypasses,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but they seem to be more beneficial after gastric sleeve procedures.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The type of endotherapy (stent, stricturotomy or dilatation) depends on the time of the postoperative period, which is divided into 4 stages: acute (<7 days), early (7–45 days), late (1.5–3 months) and chronic (>3 months). The widest (28<span class="elsevierStyleHsp" style=""></span>mm) and longest (15<span class="elsevierStyleHsp" style=""></span>cm) self-expandable metallic stents promote the occlusion of the fistula orifice, rectify the deviation from the axis of the gastric pouch and expand distal stenosis, resulting in decreased endoluminal pressure. These stents are used in acute and early stages, sometimes in late stages and very rarely in chronic stages.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Stricturotomy</span> is the incision made in the gastric stenosis, which is called septotomy when there is a septum involving the pouch wall; it is usually adjacent to the orifice of the fistulous tract and causes persistent flow as it directs the digestive secretions toward the fistula. Dividing this septum with electrocautery or argon plasma coagulation was the first effective endoluminal method for the treatment of chronic fistula after gastric sleeve surgery. We began using this approach some years ago due to the failure of isolated endoscopic dilatation in areas of intense tissue fibrosis, in late stages and in chronic cases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Thus, immediately after the incision in the tough, stenotic area, we use dilatation with a 30-mm balloon, which corrects anatomic and functional alterations.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This early endoluminal approach reduces hospitalization and intensive care times especially in gastric sleeve procedures. In these cases, chronic fistula is difficult to treat and there is a tendency for recurrence or even progression into a gastrobronchial fistula and afterwards a long-term subphrenic abscess. This situation explains why bariatric endoscopy has been substituting the riskier, more invasive classic approach of total gastrectomy.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Weight regain</span> is secondary to several causes, one of which is the increased diameter of the gastrojejunal anastomosis (>15<span class="elsevierStyleHsp" style=""></span>mm), which can be reduced through endoscopic methods favoring to weight loss. The application of argon plasma on the anastomosis is an endoscopic therapeutic option as it causes an inflammatory reaction resulting in reduction of the diameter, when it heals it causes fibrosis that is difficult to dilate. Another device, the <span class="elsevierStyleItalic">Apollo Overstitch</span>, is the newest device for endoscopic suture that allows us to reduce the diameter of the pouch and the anastomosis, and it provides internal suture of the anastomosis, reducing its diameter.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Even so, these methods are recent and require long-term studies.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Choledocholithiasis</span> appears in up to 30% of patients who undergo gastric bypass surgery. Its combined treatment (endoluminal and laparoscopic) can be done with transgastric endoscopic retrograde cholangiopancreatography (ERCP).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Simultaneously with the laparoscopic cholecystectomy, a 1-cm transgastric incision is made on the anterior side of the excluded stomach for the passage of the duodenoscope, which is introduced into the abdomen through a 15-mm trocar. The technique involves identifying the excluded stomach and performing a gastrotomy. The sterile duodenoscope is passed through the gastrotomy with the aid of the second surgeon; the endoscope reaches the duodenal papilla and the biliary duct for procedures like conventional oral ERCP.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The main complications of the <span class="elsevierStyleItalic">adjustable gastric band</span> (AGB) are distal slippage and gastric erosion, which can be treated endoscopically. In the initial stage of erosion, we recommend a wait-and-see approach until there is penetration in the stomach greater than 50% of the circumference of the AGB due to the risk of gastrointestinal bleeding or perigastric abscess, which can also be resolved by endotherapy.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> When an adequate area of intragastric migration is identified, it is resected and extracted endoscopically, with an insignificant rate of complications and excellent possibilities for success.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Band slippage causes proximal dilatation of the gastric pouch and obstructive symptoms.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Classic laparoscopic removal is indicated, and there is a risk for pulmonary aspiration. In order to avoid this complication, we recommend an endoscopic approach under mild sedation in order to aspirate the gastric stasis. Afterwards, the endoscope passes through the compression area of the AGB, it is hyperinflated and this causes slippage of the device, which can result in the repositioning of the band to its previous position.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In gastric bypass, the <span class="elsevierStyleItalic">gastrojejunal anastomosis</span> (GJA) can develop stenosis or marginal ulcer, which are treated with TTS balloon dilatation and the use of proton-pump inhibitors and sucralfate, respectively.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> When there are unabsorbable sutures or surgical staples, their endoscopic removal is also indicated to favor ulcer healing.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This can cause stenosis due to scar retraction, which may require stenotomy in the fibrotic area, followed by balloon dilatation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Reduction of the pouch diameter at the GJA or the area of compression can cause <span class="elsevierStyleItalic">impaction</span>, which initially improves with clinical measures, although the definitive solution involves endoscopic extraction.</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gastric bypass rings can cause intragastric erosion, slippage and food intolerance.</span> In these cases, the ring that has migrated toward the lumen is cut with an endoscopic clamp-scissor and extracted with foreign-body forceps. Ring slippage and food intolerance with or without gastric stenosis are treated with dilatation using a 30-mm balloon, which has a low rate of complications.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However, weight may still be regained due to the increased pouch diameter, which may be treated with the application of argon plasma. Another preventive measure is the introduction of a self-expandable metallic stent that causes an inflammatory process around the ring and promotes intragastric erosion, which is extracted together with the prosthesis after 10 days. In this region, there is fibrosis and controlled reduction of the pouch diameter, aimed at maintaining weight and proper tolerance of solid intake.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In short, bariatric endoscopy is a minimally invasive surgery and most procedures are done in the outpatient setting under sedation. This endotherapy can also be used in conjunction with surgical approaches to control complications. Furthermore, it plays a fundamental role in severe and challenging situations for surgeons, such as gastric fistulas with associated sepsis, in which the endoluminal approach has reduced morbidity and mortality compared with the traditional surgical approach. In addition, it reduces hospitalization time and intensive care requirements, which lowers overall treatment expenses.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Galvão Neto M, Marins Campos J. Endoscopia flexible terapéutica tras cirugía bariátrica: una solución a situaciones clínicas complejas. Cir Esp. 2015;93:1–3.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endoscopia en cirugía de la obesidad" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.P. Galvão Neto" 1 => "J.M. Campos" 2 => "T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 0 | 8 |
| 2024 October | 23 | 7 | 30 |
| 2024 September | 32 | 4 | 36 |
| 2024 August | 34 | 3 | 37 |
| 2024 July | 30 | 1 | 31 |
| 2024 June | 22 | 3 | 25 |
| 2024 May | 23 | 4 | 27 |
| 2024 April | 42 | 5 | 47 |
| 2024 March | 50 | 4 | 54 |
| 2024 February | 41 | 6 | 47 |
| 2024 January | 57 | 6 | 63 |
| 2023 December | 51 | 5 | 56 |
| 2023 November | 67 | 9 | 76 |
| 2023 October | 67 | 11 | 78 |
| 2023 September | 49 | 2 | 51 |
| 2023 August | 53 | 0 | 53 |
| 2023 July | 55 | 4 | 59 |
| 2023 June | 46 | 4 | 50 |
| 2023 May | 55 | 4 | 59 |
| 2023 April | 50 | 3 | 53 |
| 2023 March | 76 | 11 | 87 |
| 2023 February | 61 | 7 | 68 |
| 2023 January | 67 | 2 | 69 |
| 2022 December | 57 | 12 | 69 |
| 2022 November | 37 | 10 | 47 |
| 2022 October | 46 | 6 | 52 |
| 2022 September | 49 | 13 | 62 |
| 2022 August | 55 | 13 | 68 |
| 2022 July | 43 | 9 | 52 |
| 2022 June | 37 | 9 | 46 |
| 2022 May | 23 | 6 | 29 |
| 2022 April | 36 | 11 | 47 |
| 2022 March | 42 | 8 | 50 |
| 2022 February | 68 | 3 | 71 |
| 2022 January | 66 | 8 | 74 |
| 2021 December | 48 | 11 | 59 |
| 2021 November | 38 | 5 | 43 |
| 2021 October | 43 | 15 | 58 |
| 2021 September | 43 | 12 | 55 |
| 2021 August | 50 | 11 | 61 |
| 2021 July | 30 | 14 | 44 |
| 2021 June | 30 | 12 | 42 |
| 2021 May | 25 | 9 | 34 |
| 2021 April | 36 | 10 | 46 |
| 2021 March | 19 | 7 | 26 |
| 2021 February | 15 | 9 | 24 |
| 2021 January | 15 | 12 | 27 |
| 2020 December | 12 | 7 | 19 |
| 2020 November | 12 | 10 | 22 |
| 2020 October | 11 | 7 | 18 |
| 2020 September | 16 | 14 | 30 |
| 2020 August | 10 | 4 | 14 |
| 2020 July | 9 | 6 | 15 |
| 2020 June | 15 | 5 | 20 |
| 2020 May | 13 | 9 | 22 |
| 2020 April | 7 | 6 | 13 |
| 2020 March | 16 | 6 | 22 |
| 2020 February | 5 | 10 | 15 |
| 2020 January | 13 | 3 | 16 |
| 2019 December | 16 | 10 | 26 |
| 2019 November | 6 | 2 | 8 |
| 2019 October | 10 | 4 | 14 |
| 2019 September | 19 | 4 | 23 |
| 2019 August | 10 | 11 | 21 |
| 2019 July | 10 | 13 | 23 |
| 2019 June | 29 | 19 | 48 |
| 2019 May | 106 | 18 | 124 |
| 2019 April | 34 | 13 | 47 |
| 2019 March | 6 | 2 | 8 |
| 2019 February | 8 | 5 | 13 |
| 2019 January | 10 | 10 | 20 |
| 2018 December | 7 | 7 | 14 |
| 2018 November | 3 | 9 | 12 |
| 2018 October | 18 | 4 | 22 |
| 2018 September | 7 | 4 | 11 |
| 2018 August | 7 | 2 | 9 |
| 2018 July | 13 | 2 | 15 |
| 2018 June | 13 | 1 | 14 |
| 2018 May | 5 | 1 | 6 |
| 2018 April | 9 | 0 | 9 |
| 2018 March | 5 | 1 | 6 |
| 2018 February | 9 | 2 | 11 |
| 2018 January | 7 | 0 | 7 |
| 2017 December | 10 | 1 | 11 |
| 2017 November | 11 | 1 | 12 |
| 2017 October | 15 | 4 | 19 |
| 2017 September | 9 | 2 | 11 |
| 2017 August | 17 | 1 | 18 |
| 2017 July | 13 | 0 | 13 |
| 2017 June | 24 | 1 | 25 |
| 2017 May | 29 | 3 | 32 |
| 2017 April | 23 | 1 | 24 |
| 2017 March | 30 | 43 | 73 |
| 2017 February | 10 | 0 | 10 |
| 2017 January | 19 | 3 | 22 |
| 2016 December | 12 | 5 | 17 |
| 2016 November | 17 | 3 | 20 |
| 2016 October | 36 | 18 | 54 |
| 2016 September | 28 | 4 | 32 |
| 2016 August | 23 | 4 | 27 |
| 2016 July | 17 | 2 | 19 |
| 2016 June | 27 | 13 | 40 |
| 2016 May | 39 | 12 | 51 |
| 2016 April | 34 | 11 | 45 |
| 2016 March | 31 | 15 | 46 |
| 2016 February | 28 | 13 | 41 |
| 2016 January | 31 | 15 | 46 |
| 2015 December | 35 | 10 | 45 |
| 2015 November | 25 | 2 | 27 |
| 2015 October | 23 | 8 | 31 |
| 2015 September | 35 | 9 | 44 |
| 2015 August | 20 | 6 | 26 |
| 2015 July | 20 | 8 | 28 |
| 2015 June | 13 | 1 | 14 |
| 2015 May | 16 | 5 | 21 |
| 2015 April | 7 | 4 | 11 |
| 2015 February | 0 | 1 | 1 |
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