AGA Clinical Practice Update on Evaluation and Management of Early Complications After Bariatric/Metabolic Surgery: Expert Review
Authors: Vivek Kumbhari, David E. Cummings, Anthony N. Kalloo, Philip R. Schauer
Journal: Clinical Gastroenterology and Hepatology (2021)

DescriptionEndoscopic techniques are paramount in the identification and management of complications after surgery, though collaboration with other specialties is obligatory. Unfortunately, the evaluation and treatment algorithms are not standardized and there is a paucity of high-quality prospective studies to provide clarity regarding the best approach. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery.MethodsThe best practice advice outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable.Best Practice Advice 1Clinicians 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 2Clinicians 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 3Clinicians 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 4Clinicians 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 5Endoscopic 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 6Clinicians 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 7Clinicians should recognize that the goal for endoscopic management of staple-line leaks are 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. Endoscopic techniques are paramount in the identification and management of complications after surgery, though collaboration with other specialties is obligatory. Unfortunately, the evaluation and treatment algorithms are not standardized and there is a paucity of high-quality prospective studies to provide clarity regarding the best approach. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery. The best practice advice outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. 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. 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. 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. 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. 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. 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. Clinicians should recognize that the goal for endoscopic management of staple-line leaks are 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. Bariatric/metabolic surgery is one of the most common elective general surgical procedure performed in the United States, with approximately 205,000 such primary operations performed in 2018 alone.1American Society for Metabolic and Bariatric SurgeryEstimate of bariatric surgery numbers, 2011-2018. March 2020.https://asmbs.org/resources/estimate-of-bariatric-surgery-numbersGoogle Scholar Of these, approximately 95% (198,000) were either sleeve gastrectomy (SG) (155,000) or Roux-en-Y gastric bypass (RYGB) (43,000).1American Society for Metabolic and Bariatric SurgeryEstimate of bariatric surgery numbers, 2011-2018. March 2020.https://asmbs.org/resources/estimate-of-bariatric-surgery-numbersGoogle Scholar With the increasing adoption of bariatric/metabolic surgery, clinicians will more frequently encounter patients who suffer complications, despite advancements in surgical techniques. The 90-day mortality rate from bariatric or metabolic surgery is very low, at 0.1%–0.3%.2Nasser H. Munie S. Kindel T.L. et al.Comparative analysis of robotic versus laparoscopic revisional bariatric surgery: perioperative outcomes from the MBSAQIP database.Surg Obes Relat Dis. 2020; 16: 397-405Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,3Tao W. Plecka-Ostlund M. Lu Y. et al.Causes and risk factors for mortality within 1 year after obesity surgery in a population-based cohort study.Surg Obes Relat Dis. 2015; 11: 399-405Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The 90-day overall complication rate is 7%–10%, with 4% being major complications.2Nasser H. Munie S. Kindel T.L. et al.Comparative analysis of robotic versus laparoscopic revisional bariatric surgery: perioperative outcomes from the MBSAQIP database.Surg Obes Relat Dis. 2020; 16: 397-405Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,4Leeman M. van Mil S.R. Biter L.U. et al.Reducing complication rates and hospital readmissions while revising the enhanced recovery after bariatric surgery (ERABS) protocol.Surg Endosc. 2021; 35: 612-619Crossref PubMed Scopus (4) Google Scholar However, in patients >65 years of age, the 90-day mortality rate is higher, at 1.3%, with an overall complication rate of 20.1%.5Petrick A.T. Kuhn J.E. Parker D.M. et al.Bariatric surgery is safe and effective in Medicare patients regardless of age: an analysis of primary gastric bypass and sleeve gastrectomy outcomes.Surg Obes Relat Dis. 2019; 15: 1704-1711Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The principal method of diagnosing and treating many early complications is flexible endoscopy. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery. Patients who have undergone bariatric/metabolic surgery often have comorbidities and the occurance of a major early complication further complicates their management. The complexity of these circumstances, together with the composite of anatomical, physiological, and pathological alterations, impels a multidisciplinary approach often involving multiple interventions over a prolonged duration.6Kumbhari V. Cai J.X. Schweitzer M.A. Endoscopic management of bariatric surgical complications.Curr Opin Gastroenterol. 2015; 31: 359-367Crossref PubMed Scopus (12) Google Scholar Timely communication between the endoscopist, radiologist, surgeon, nutritionists, and inpatient medical team or primary care physician will result in efficient, effective care with prompt escalation and de-escalation. As there are no consensus-based algorithms to guide the care teams, medical decisions can change rapidly, causing anxiety and frustration for patients. Daily communication should occur among all providers during dynamic phases, either at the bedside or via a portal (secure email, electronic health record, standing phone call, etc.). For example, the interventional radiologist can provide advice on optimal imaging (upper gastrointestinal series vs oral/intravenous contrast computed tomography scan), prospects of placing a percutaneous drain into a perigastric collection, etc.7Kalff M.C. de Raaff C.A.L. de Vries C.E.E. et al.Diagnostic value of computed tomography for detecting anastomotic or staple line leakage after bariatric surgery.Surg Obes Relat Dis. 2018; 14: 1310-1316Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The surgeon can advise on the anticipated morbidity of a laparoscopic Roux-en-Y fistulojejunostomy as a treatment for leak post-SG, information critical to ascertaining whether pursuing "out-of-the-box" endoscopic approaches should be considered. Clinicians performing endoscopic management, in addition to reviewing the operative report, should have detailed knowledge and experience with postsurgical anatomy. Experience with the endoscopic appearances SG and RYGB patients is necessary to allow for the recognition of the staple line, what constitutes a stenosis or stricture, diameter and length of stent required, and to allow for meaningful discussion with the surgeon and radiologist. The endsocopist should also have expertise in interventional endoscopy techniques, including but not limited to using concomitant fluoroscopy, stent deployment and retrieval, pneumatic balloon dilation, incisional therapies, endoscopic suturing, and managing percutaneous drains.8Jirapinyo P. Thompson C.C. How to incorporate bariatric training into your fellowship program.Gastroenterology. 2019; 157: 9-13Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Having the ability to perform a wide array of therapies will enhance the likelihood that the optimal endoscopic strategy will be employed, as opposed to simply performing a technique with which the endoscopist has experience. Clinicians should evaluate all patients for comorbid medical conditions (nutrient deficiencies, infection, pulmonary embolism) and psychological problems (depression, anxiety). Patients with complications that result in deficient oral intake from prolonged fasting (eg, leaks), or frequent regurgitation (obstruction and/or severe reflux) are susceptible to dehydration as well as macro- and micronutrient deficiencies that should be treated.9Mechanick J.I. Apovian C. Brethauer S. et al.Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, the Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists - Executive Summary.Endocr Pract. 2019; 25: 1346-1359PubMed Google Scholar In particular, patients suffering severe and persistent vomiting who are about to undergo emergent general anesthesia (often with paralysis) for endoscopy should be tested and treated for potassium deficiency. Additionally, in the weeks following surgery, individuals should be screened regularly and prophylactically treated for thiamine deficiency, particularly as Wernicke's encephalopathy has been reported among patients with complications.10Oudman E. Wijnia J.W. van Dam M. et al.Preventing Wernicke encephalopathy after bariatric surgery.Obes Surg. 2018; 28: 2060-2068Crossref PubMed Scopus (50) Google Scholar,11Tang L. Alsulaim H.A. Canner J.K. et al.Prevalence and predictors of postoperative thiamine deficiency after vertical sleeve gastrectomy.Surg Obes Relat Dis. 2018; 14: 943-950Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar In patients with severe food intolerance and concomitant proton pump inhibitor usage, evaluation should include testing for magnesium and calcium deficiency.12Taylor D.M. Date P.A. Ugoni A. et al.Risk variables associated with abnormal calcium, magnesium and phosphate levels among emergency department patients.Emerg Med Australas. 2020; 32: 303-312Crossref PubMed Scopus (4) Google Scholar Patients often have higher depression and anxiety scores, as well as a lower physical quality of life, and medical teams sometimes neglect the patients' psychological state.13Ho K. Hawa R. Wnuk S. et al.The psychosocial effects of perioperative complications after bariatric surgery.Psychosomatics. 2018; 59: 452-463Crossref PubMed Scopus (12) Google Scholar It is imperative that the multidisciplinary team recognize and acknowledge the patients psychological comorbidities and engage expertise to manage them. Endoscopic approaches should be considered for patients regardless of the time interval from surgery, including the immediate postoperative period. Common reasons for performing endoscopy are a result of persistent upper gastrointestinal bleeding, obstruction due to severe torsion of the gastric lumen or at the gastrojejunal (GJ) anastomosis, or acute staple-line leak.14Modasi A. Dang J.T. Afraz S. et al.Bariatric surgery outcomes in patients on preoperative therapeutic anticoagulation: an analysis of the 2015 to 2017 MBSAQIP.Obes Surg. 2019; 29: 3432-3442Crossref PubMed Scopus (5) Google Scholar In each of these circumstances, endoscopy is often indicated as the initial therapeutic modality, and it can safely be performed.15Campos J.M. Moon R. Teixeira A. et al.Endoscopic management of massive hemorrhage 12 h post laparoscopic Roux-en-Y gastric bypass.Obes Surg. 2015; 25: 1981-1983Crossref PubMed Scopus (3) Google Scholar When endoscopy is performed, it is advised to use carbon dioxide for insufflation. Caution should be used when advancing the endoscope into the small bowel, as it is best to minimize pressure along the fresh staple lines. In cases in which the patient is critically ill or the interventional endoscopist does not have extensive experience with such a scenario, the endoscopy should be performed in the operating room with a surgeon present (preferably the surgeon who performed the operation). Intraluminal bleeding (there should also be a suspicion for extraluminal bleeding in the early postoperative period) most commonly occurs at the staple lines or as a result of acute ulcer formation (eg, a marginal ulcer in patients that have undergone a RYGB). Owing to the small caliber lumens post-SG and RYGB, in addition to the body habitus, there should be a low threshold to perform the procedure under general anesthesia with airway protection. If bleeding is massive, consider placement of an overtube to allow for easy removal of clot burden.15Campos J.M. Moon R. Teixeira A. et al.Endoscopic management of massive hemorrhage 12 h post laparoscopic Roux-en-Y gastric bypass.Obes Surg. 2015; 25: 1981-1983Crossref PubMed Scopus (3) Google Scholar To achieve hemostasis, consider using mechanical techniques such as through-the-scope (TTS) clips in preference over thermal ablative methods to minimize the risk of a consequent leak at the site. Where TTS clips fail to achieve hemostasis, alternatives include hemostatic powders (TC-325: Hemospray, Cook Medical, Winston-Salem, NC), over-the-scope clips (OTSCs) (Ovesco Endoscopy [Tübingen, Germany]; Padlock clip [Aponos Medical Co., Kingston, NH]), and endoscopic suturing (Overstitch; Apollo Endosurgery, Austin, TX).16Chandrasekar V.T. Desai M. Aziz M. et al.Efficacy and safety of over-the-scope clips for gastrointestinal bleeding: a systematic review and meta-analysis.Endoscopy. 2019; 51: 941-949Crossref PubMed Scopus (13) Google Scholar,17Barola S. Magnuson T. Schweitzer M. et al.Endoscopic suturing for massively bleeding marginal ulcer 10 days post Roux-en-Y gastric bypass.Obes Surg. 2017; 27: 1394-1396Crossref PubMed Scopus (10) Google Scholar The use of mechanical techniques will also allow the patient to promptly restart prophylaxis for venous thromboembolism. The etiology of acute obstruction is usually different from that which presents weeks to months after surgery. Acutely, postoperative edema or a hematoma at the anastomosis can occur. If an endoscopy is performed within hours or days of surgery to manage an obstruction, placement of a self-expandable metallic stent (SEMS) should be considered. If the obstruction occurs in a patient who has undergone a SG and is at the level of the incisura angularis or at the site of a prior laparoscopic adjustable gastric band, placement of a covered esophageal SEMS secured with endoscopic suturing or the stentfix OTSC (Ovesco Endoscopy) may be preferred.18Fayad L. Simsek C. Oleas R. et al.Safety and efficacy of endoscopically secured fully covered self-expandable metallic stents (FCSEMS) for post-bariatric complex stenosis.Obes Surg. 2019; 29: 3484-3492Crossref PubMed Scopus (7) Google Scholar Securing the stent is mandatory as the distal end of the stent may reside distal to the pylorus or GJ anastomosis. If the obstruction is at the GJ anastomosis in a patient who has undergone a RYGB, placement of a lumen-apposing metal stent (Boston Scientific, Marlborough, MA) can be performed if the anatomy permits.19Simsek C. Ichkhanian Y. Fayad L. et al.Secured lumen-apposing fully covered metallic stents for stenoses in post-bariatric surgery patients.Obes Surg. 2019; 29: 2695-2699Crossref PubMed Scopus (4) Google Scholar Large-caliber stents (15–20 mm) are safe to use and will not cause dehiscence of the fresh staple lines. Downstream stenosis is frequently seen at the level of the incisura angularis or in the proximal stomach when a SG is performed in a patient with a prior laparoscopic adjustable gastric band. Aggressive dilation of downstream stenosis using large pneumatic balloons (Wilson-Cook or Boston Scientific) can be performed to further reduce intraluminal gastric pressure.20Chang S.H. Popov V.B. Thompson C.C. Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis.Gastrointest Endosc. 2020; 91: 989-1002.e4Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The balloons are 8- to 10-cm long and range from 30 to 40 mm in diameter, though dilation should rarely exceed 35 mm. These dilations are performed with the endoscope side-by-side to the balloon (as opposed to dilating a GJ anastomotic stricture, which would be performed with TTS balloons), such that endoscopic and fluoroscopic views can be maintained throughout the dilation process.21Agnihotri A. Barola S. Hill C. et al.An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.Obes Surg. 2017; 27: 2628-2636Crossref PubMed Scopus (29) Google Scholar Fluoroscopy is recommended (though not mandatory) to ensure the distal aspect of the balloon has not inadvertently crossed the pylorus. The endoscope is placed flush on the proximal aspect of the balloon, and an isolated ischemic ring should be seen at the site of stenosis. If there is confluent blanching of the mucosa, the sleeve lumen itself may be too small for this approach. The balloon should be inflated to 20 psi for 1–3 minutes, and reinspection should be performed to assess for a tear.21Agnihotri A. Barola S. Hill C. et al.An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.Obes Surg. 2017; 27: 2628-2636Crossref PubMed Scopus (29) Google Scholar If the tear appears to involve the muscularis propria or beyond, endoscopic suturing should be attempted to close the defect.22Dolan R.D. Varban O.A. Schulman A.R. Endoscopic repair of large gastric perforation following pneumatic dilation of sleeve gastrectomy stenosis.Obes Surg. 2020; 30: 2046-2049Crossref PubMed Scopus (4) Google Scholar If there is obscurity regarding the presence of a perforation, contrast can be injected to flood the stomach and assess for extravasation. Dilations can be performed as early as 2 weeks after surgery. For stenosis at the incisura angularis that does not respond adequately after 2–3 dilations (each being performed 2–4 weeks apart) and to a maximum diameter of 35 mm, an alternative technique should be employed. A large-diameter fully covered SEMS (FCSEMS) up to 60 mm long can be deployed across the stenosis and secured in position for 2 months.21Agnihotri A. Barola S. Hill C. et al.An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.Obes Surg. 2017; 27: 2628-2636Crossref PubMed Scopus (29) Google Scholar The sole purpose of the stent would be to improve pressure and flow dynamics, as opposed to cover the leak site. As these stents should not cross gastroesophageal junction, they are generally well tolerated.21Agnihotri A. Barola S. Hill C. et al.An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.Obes Surg. 2017; 27: 2628-2636Crossref PubMed Scopus (29) Google Scholar Staple-line leaks most commonly occur along the staple line of the proximal stomach (immediately below the angle of His in patients after SG and at the GJ anastomosis after RYGB).23Rosenthal R.J. International Sleeve Gastrectomy Expert P. Diaz A.A. et al.International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases.Surg Obes Relat Dis. 2012; 8: 8-19Abstract Full Text Full Text PDF PubMed Scopus (643) Google Scholar With respect to SG, surgeons may leave a small fundal pouch or "dog ear" in this area to decrease stapling too close to the esophagus. The pathophysiologic mechanisms behind leak formation in this location are thought to relate to ischemia secondary to take down of the short gastric arteries, mismatch in staple height selection due to the thinner wall of the gastric fundus, downstream stenosis at the incisura angularis at SG, and high intraluminal pressures within a poorly compliant stomach in SG. Hence, most leaks are not present upon completion of the operation, and they develop over the subsequent weeks, often in the setting of downstream stenosis. Endoscopic management strategies described below to treat leaks are relevant to both SG and RYGB. Endoscopic approaches are generally more successful for early and acute leaks (<6 weeks from surgery), whereas chronic leaks are more likely to require multiple endoscopies using a variety of strategies with recalcitrant cases benefitting from salvage surgical management (Figure 1). Historically, treatment had been aimed at facilitating percutaneous drainage (interventional radiology or surgical), followed by endoscopic closure of the leak. Techniques used include endoscopic suturing and OTSC, although recurrent leak is frequent when primary closure methods are used in isolation.24Lamb L.C. Lawlor M.K. Tishler D.S. et al.Use of an endoscopic suturing platform for the management of staple line dehiscence after laparoscopic sleeve gastrectomy.Obes Surg. 2020; 30: 895-900Crossref PubMed Scopus (3) Google Scholar,25Shoar S. Poliakin L. Khorgami Z. et al.Efficacy and safety of the over-the-scope clip (OTSC) system in the management of leak and fistula after laparoscopic sleeve gastrectomy: a systematic review.Obes Surg. 2017; 27: 2410-2418Crossref PubMed Scopus (34) Google Scholar Mechanisms behind failure are thought to be secondary to the following: (1) poor integrity of the tissue surrounding the leak as a result of ischemia and inflammation, (2) difficulty obtaining a perpendicular endoscopic view of the leak for optimal repair, and (3) failure to address high intraluminal pressures caused by downstream gastric stenosis or anastomotic stricture.26Kumbhari V. Abu Dayyeh B.K. Keeping the fistula open: paradigm shift in the management of leaks after bariatric surgery?.Endoscopy. 2016; 48: 789-791Crossref PubMed Scopus (9) Google Scholar,27Vargas E.J. Abu Dayyeh B.K. Keep calm under pressure: a paradigm shift in managing postsurgical leaks.Gastrointest Endosc. 2018; 87: 438-441Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar More recent techniques, such as those described subsequently, better address the underlying precipitating and propagating factors contributing to the leak. Diversion therapy using SEMS can be useful when combined with percutaneous drainage for early leaks.28Murino A. Arvanitakis M. Le Moine O. et al.Effectiveness of endoscopic management using self-expandable metal stents in a large cohort of patients with post-bariatric leaks.Obes Surg. 2015; 25: 1569-1576Crossref PubMed Scopus (33) Google Scholar Diversion therapy facilitates early commencement of diet and when longer length stents are used, it can addressees downstream gastric stenosis.29de Moura D.T.H. de Moura E.G.H. Neto M.G. et al.Outcomes of a novel bariatric stent in the management of sleeve gastrectomy leaks: a multicenter study.Surg Obes Relat Dis. 2019; 15: 1241-1251Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Both partially covered SEMS (PCSEMS) and FCSEMS have been used for this purpose; however, a dichotomy exists. If a FCSEMS is used, it is essential to secure it in order to decrease the risk of migration. Furthermore, diversion may be suboptimal as the seal is not "watertight," owing to oral contents passing alongside the stent. PCSEMS negate these aforementioned concerns, but stent removal is challenging. PCSEMS should have a maximum diameter of 18 mm in the body of the stent and should dwell for a maximum of 3–4 weeks.30Hill C. Khalil B.K. Barola S. et al.Inversion Technique for the Removal of Partially Covered Self-Expandable Metallic Stents.Obes Surg. 2018; 28: 161-168Crossref PubMed Scopus (7) Google Scholar Techniques used to remove PCSEMS include inverting the stent by grasping its terminal end and removing it using sufficient force, or placing a larger diameter (20-mm diameter in the body of the stent) FCSEMS inside the PCSEMS and removing both 1 week later.30Hill C. Khalil B.K. Barola S. et al.Inversion Technique for the Removal of Partially Covered Self-Expandable Metallic Stents.Obes Surg. 2018; 28: 161-168Crossref PubMed Scopus (7) Google Scholar Regardless of stent type placed, there is often tissue invagination and ulceration at the distal aspect of the stent resulting in poor tolerability by patients. Clinicians managing these patients recognize that techniques attempting to close the leak might not be the ideal treatment strategy, particularly after 6 weeks, when the leak site is mature and epithelialized. Therefore, facilitating internal drainage by "keeping the fistula open" maybe a superior approach than closing the leak orifice.26Kumbhari V. Abu Dayyeh B.K. Keeping the fistula open: paradigm shift in the management of leaks after bariatric surgery?.Endoscopy. 2016; 48: 789-791Crossref PubMed Scopus (9) Google Scholar,27Vargas E.J. Abu Dayyeh B.K. Keep calm under pressure: a paradigm shift in managing postsurgical leaks.Gastrointest Endosc. 2018; 87: 438-441Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The rationale for internal drainage is based on the concept that when the pressure within the gastric lumen is lower than that of the perigastric collection, contents will preferentially flow out of the collection and into the stomach. Additionally, oral contents will preferentially flow through the gastric lumen, as opposed to flowing against a pressure gradient through the leak.31Giuliani A. Romano L. Marchese M. et al.Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review.Surg Obes Relat Dis. 2019; 15: 1414-1419Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar For internal drainage to conceivably work as a sole strategy, the following should not be present: the perigastric collection is disorganzied, there is high intragastric pressure secondary to downstream stenosis, or there is existence of a gastropleural fistula. Once the contents of the perigastric cavity have emptied, the cavity will contract until it is obliterated, resolving the leak. When evaluating the response to therapy, the ability to tolerate diet as well as a decrease in the size of the perigastric cavity are markers of success, as opposed to a decrease in the size of the leak orifice.32Dammaro C. Lainas P. Dumont J.L. et al.Endoscopic internal drainage coupled to prompt external drainage mobilization is an effective approach for the treatment of complicated cases of sleeve gastrectomy.Obes Surg. 2019; 29: 2929-2935Crossref PubMed Scopus (14) Google Scholar If the patient's clinical state worsens and the cavity has increased in size, the pressure in the gastric lumen is not sufficiently diminished relative to the perigastric collection. This is likely the result of persistent downstream stenosis. Internal drainage is most commonly achieved by 3 approaches: placement of double pigtail stent/s through the leak, septotomy or endoscopic vacuum therapy (EVT). Where there is infected debris in the perigastric cavity, necrosectomy expedites clinical improvement and should be performed every 2 weeks until the cavity is clean. In addition, if a percutaneous drain exists or the patient is not clinically and radiologically responding in a timely manner, aggressive lavage of the collection via a percutaneous drain every 4–6 hours should be performed. If left to continuous free drainage, percutaneous drains result in a reduction of pressure within the perigastric collection, which will prevent internal drainage of material into the gastric lumen. Therefore, if a percutaneous drain is being used, it should be clamped and only opened when performing the lavage. Double pigtail stents are the preferred technique to septotomy when there is a small-caliber tract connecting the leak orifice to the collection. Short- and smaller-caliber stents should be used (7F × 3 cm or 7F × 5 cm) to minimize damage to gastric and extragastric structures.33Bouchard S. Eisendrath P. Toussaint E. et al.Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract.Endoscopy. 2016; 48: 809-816Crossref PubMed Scopus (32) Google Scholar One or 2 stents can be deployed, depending on the size of the leak orifice. Routine stent exchange should be performed every 2–4 weeks until the perigastric cavity has contracted and is too small to accommodate a stent (usually <2 cm in size). Frequent endoscopies also allow the opportunity to address any downstream functional stenosis or GJ anastomotic stricture. The rationale behind septotomy is similar to that of a Zenker's diverticulum.34Baretta G. Campos J. Correia S. et al.Bariatric postoperative fistula: a life-saving endoscopic procedure.Surg Endosc. 2015; 29: 1714-1720Crossref PubMed Scopus (43) Google Scholar To equalize the pressures between the gastric and perigastric cavity, the septum is cut along the staple line to the base of the perigastric cavity.34Baretta G. Campos J. Correia S. et al.Bariatric postoperative fistula: a life-saving endoscopic procedure.Surg Endosc. 2015; 29: 1714-1720Crossref PubMed Scopus (43) Google Scholar The cautery-enhanced TTS scissors are the current best accessories to use to perform septotomy.35Yu J.X. Schulman A.R. Management of a refractory leak after sleeve gastrectomy: the endoscopic armamentarium.VideoGIE. 2019; 4: 372-374Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Ideally, the entire septum should be cut in a single session. Bleeding is rare at the staple line, and the technique is safe as long as the cut does not extend beyond the base of the perigastric cavity. This method may be superior to double pigtail stenting for large leak orifices and those where the perigastric collection is in immediate proximity to the stomach.36Mahadev S. Kumbhari V. Campos J.M. et al.Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections.Endoscopy. 2017; 49: 504-508Crossref PubMed Scopus (29) Google Scholar EVT using a sponge connected to a nasogastric tube is increasingly being used, with success rates exceeding 80%. There are 2 broad approaches: intracavitary and intraluminal.37de Moura D.T.H. de Moura B. Manfredi M.A. et al.Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects.World J Gastrointest Endosc. 2019; 11: 329-344Crossref PubMed Google Scholar Traditional intracavitary EVT requires the placement of a sponge drainage system through the leak orifice into the perigastric cavity. The applied negative pressure promotes drainage of the infection and improves tissue perfusion.38Archid R. Wichmann D. Klingert W. et al.Endoscopic vacuum therapy for staple line leaks after sleeve gastrectomy.Obes Surg. 2020; 30: 1310-1315Crossref PubMed Scopus (15) Google Scholar In the case of the intraluminal EVT, the sponge drainage system is placed within the lumen of the stomach overlying the leak. This avoids the need for dilatation of the leak orifice to place the sponge system when the defects are small. When a traditional sponge is used, it needs to be replaced every 3 days to avoid the sponge becoming adherent to tissue.38Archid R. Wichmann D. Klingert W. et al.Endoscopic vacuum therapy for staple line leaks after sleeve gastrectomy.Obes Surg. 2020; 30: 1310-1315Crossref PubMed Scopus (15) Google Scholar To minimize the frequency of exchanges, a handmade open-pore film drainage system has been reported. Here, the sponge is replaced by wrapping gauze around a nasogastric tube and then wrapping it with a thin plastic film (eg, plastic covering used during laparoscopy), making it much smaller in diameter than conventional foams sponges.38Archid R. Wichmann D. Klingert W. et al.Endoscopic vacuum therapy for staple line leaks after sleeve gastrectomy.Obes Surg. 2020; 30: 1310-1315Crossref PubMed Scopus (15) Google Scholar In addition to facilitating intracavitary placement, it appears to be less adhesive to the gastric wall and hence reduces tissue ingrowth and bleeding on removal. The open-pore drainage system can be replaced every 7 days. Regardless of technique used, nutrition should be provided parenterally. In the event that none of the aforementioned therapies are successful, a cardiac septal occluder can be placed across the leak site.39Baptista A. Hourneaux De Moura D.T. Jirapinyo P. et al.Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas.Gastrointest Endosc. 2019; 89: 671-679.e1Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Experience is limited, and it is unclear if the occluder will embed in the digestive tract in a similar way as it does in the vascular environment. Surgical management should also be offered because by this juncture, several weeks or months may have passed since leak diagnosis.40Nedelcu M. Danan M. Noel P. et al.Surgical management for chronic leak following sleeve gastrectomy: review of literature.Surg Obes Relat Dis. 2019; 15: 1844-1849Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar There are 3 commonly proposed revision operations: fistulojejunostomy, conversion from SG to RYGB (without gastrectomy), and total or near-total gastrectomy with esophagojejunal anastomosis.41Landreneau J.P. Strong A.T. Rodriguez J.H. et al.Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.Obes Surg. 2018; 28: 3843-3850Crossref PubMed Scopus (35) Google Scholar, 42Frieder J.S. Aleman R. Gomez C.O. et al.Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience.Surg Obes Relat Dis. 2020; 16: 983-990Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 43Vidarsson B. Sundbom M. Edholm D. Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: a cohort study of 40,844 patients.Surg Obes Relat Dis. 2019; 15: 1075-1079Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Direct surgical repair of the chronic leak site is rarely effective and not advised. Bariatric/metabolic surgery is unmatched with respect to its weight loss and metabolic benefits. The selection criteria will continue to broaden, likely resulting in increasing numbers of less robust patients undergoing surgery (eg, children, elderly, and those with significant cardiorespiratory comorbidities). As utilization escalates, so will the number of patients who suffer early complications. Therefore, it is imperative that the endoscopist have the aptitude to efficiently evaluate and manage 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 awareness to escalate to more invasive surgical management when necessary.