Evaluation and management of early complications after bariatric surgery: AGA Guideline

USA: Endoscopic techniques are important for the identification and management of complications after surgery. However, there are no standardized evaluation and treatment algorithms and there is a lack of high-quality prospective studies to provide clarity on the best approach.

Against the above background, the American Gastroenterological Association (AGA) has released an updated guideline on the endoscopic evaluation and management of early complications after bariatric/metabolic surgery. The guideline is published in the journal Clinical Gastroenterology and Hepatology.

Vivek Kumbhari, Johns Hopkins School of Medicine, Baltimore, Maryland, and colleagues outlined the best practice advice in the expert review. The best practice advice is based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. 

Best Practice Advice 1

Clinicians performing endoscopic approaches to treat early major postoperative complications should do so in a multidisciplinary manner with interventional radiology and bariatric/metabolic surgery co-managing the patient. Daily communication is advised.

Best Practice Advice 2

Clinicians embarking on incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a comprehensive knowledge of the indications, contraindications, risks, benefits, and outcomes of each of the endoscopic treatment techniques. They should also have knowledge of the risks and benefits of alternative methods such as surgical and interventional radiological-based approaches.

Best Practice Advice 3

Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have expertise in interventional endoscopy techniques, including but not limited to: using concomitant fluoroscopy, stent deployment, and retrieval, managing stenosis, and managing percutaneous drains. 

Best Practice Advice 4

Clinicians should screen all patients undergoing endoscopic management of bariatric/metabolic surgical complications and dietary intolerance for comorbid medical (nutrient deficiencies, infection, pulmonary embolism) and psychological (depression, anxiety) conditions.

Best Practice Advice 5

Endoscopic approaches to managing complications of bariatric/metabolic surgery may be considered for patients in the immediate, early and late postoperative periods depending on hemodynamic stability.

Best Practice Advice 6

Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a detailed understanding of the pathophysiologic mechanisms initiating and perpetuating conditions such as staple-line leaks. This will allow for a prompt diagnosis and appropriate therapy to be targeted not only at the area of interest, but also any concomitant downstream stenosis.

Best Practice Advice 7

Clinicians should recognize that the goal for endoscopic management of staple-line leaks is often not necessarily initial closure of the leak site, but rather techniques to promote drainage of material from the perigastric collection into the gastric lumen such that the leak site closes by secondary intention.

To conclude, the researchers wrote that bariatric surgery has numerous weight loss and metabolic benefits. The selection criteria will continue to broaden resulting in an increasing number of less robust patients undergoing surgery. With increasing utilization, the number of patients who suffer early complications will also increase. Therefore, it is imperative that the endoscopist have the aptitude for effective evaluation and management of patients in a collaborative, multidisciplinary manner. Their role is to ascertain the anatomical contributors to the complication and then offer patients the myriad of therapies (behavioral, medical, endoscopic, and surgical) required to address them.

The endoscopist should have the knowledge, experience, and resources to modify and progress from one endoscopic technique to another, as well as have the awareness to escalate to more invasive surgical management when necessary.

Reference:

"AGA Clinical Practice Update on Evaluation and Management of Early Complications After Bariatric/Metabolic Surgery: Expert Review," is published in the journal Clinical Gastroenterology and Hepatology.

DOI: https://www.cghjournal.org/article/S1542-3565(21)00330-X/fulltext