University of South Florida Morsani College of Medicine, Tampa, FL, USA.
Department of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA.
Surg Endosc. 2024 May;38(5):2894-2899. doi: 10.1007/s00464-024-10799-7. Epub 2024 Apr 17.
Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure.
A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines.
Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%.
Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.
减重手术后发生渗漏虽然罕见，但由于有发生腹膜炎和败血症的风险，可能是致命的。Roux-en-Y 胃旁路术（RYGB）后的吻合口渗漏和胃-胃瘘，以及袖状胃切除术后的吻合线渗漏，历史上一直采用多种方式治疗，包括手术引流、积极的抗生素治疗，以及最近的内镜治疗。内镜夹闭术使用过内镜夹和内镜缝合是两种最常见的实现全层闭合的方法。
在 PubMed 上进行了系统的文献检索，以确定关于使用内镜夹闭或缝合治疗减重手术后渗漏和瘘的文章。排除了专注于支架的研究，以及同时合并多种闭合技术的研究。采用 PRISMA 指南进行文献复习和荟萃分析。
纳入了 5 项共 61 例接受过内镜夹闭（OTS）的研究。汇总研究中成功闭合的比例为 81.1%（95%CI 67.3%至 91.7%）。成功闭合率具有同质性（I=39%，p=0.15）。纳入了 3 项共 92 例接受内镜缝合的研究。汇总研究中成功闭合的比例为 22.4%（95%CI 14.6%至 31.3%）。成功闭合率具有同质性（I=0%，p=0.44）。3 项共 34 例研究报告了 OTS 部署后的再次干预率数据。汇总研究中再次干预的比例为 35.0%（95%CI 11.7%至 64.7%）。我们发现统计学上存在显著的异质性（I=68%，p=0.04）。一项共 20 例患者的研究报告内镜缝合后的再次干预率为 60%。
观察性报告显示，接受 OTS 治疗的患者比接受内镜缝合治疗的患者更有可能治愈其缺陷。应开展更大规模的对照研究，比较不同的减重手术漏缝闭合装置，以更好地了解这些并发症的理想内镜治疗方法。
