Efficacy and safety of self-expandable metal stents for management of bariatric surgery leaks. A systematic review and meta-analysis
Khan MA, Saumoy M, Iqbal U, Haq KF, Khan A, Kamal F, Zuchelli T, Anwar H, Mohammed Abdul MK, and Sharaiha RZ. Efficacy and safety of self-expandable metal stents for management of bariatric surgery leaks. A systematic review and meta-analysis. Gastrointestinal Endoscopy 2020; 91(6):AB231-AB232.
Background: Post bariatric surgery leaks can be difficult to manage, and surgical re-exploration is associated with significant morbidity and mortality. Endoscopic deployment of self-expandable metal stents (SEMS) is a less invasive modality and has been utilized for management of such leaks avoiding the need for re-exploration surgery in selected patients. Aim: Conduct a systematic review and meta-analysis to evaluate the efficacy and safety of endoscopically placed SEMS for management of post bariatric surgery leaks. Methods: We searched Medline, Embase and Cochrane library from inception through November 26, 2019 to identify studies evaluating the efficacy of SEMS for treatment of post bariatric surgery leaks. The primary outcome of interest was rate of successful closure of leaks determined radiologically after removal of SEMS. Secondary outcomes included rates of successful stent removal and adverse events including rate of stent migration. These outcomes were presented as weighted pooled rates WPR and analyzed using random effects model of meta-analysis. Publication bias was calculated with funnel plots and Beg Mazumdar test. Duval and Tweedie’s trim and fill test was used to adjust for publication bias. To avoid inherent bias associated with case reports and small case series only studies with at least 10 patients were included. NIH tool was used for single arm before-after studies for quality assessment of individual studies. Results: A total of 19 observational studies with 539 patients with post-surgery leaks were included in this systematic review and meta-analysis. Among the patients, 58% were females. 22% of patients had undergone Roux-en-Y bypass surgery, 73% % had laparoscopic sleeve gastrectomy 2% had duodenal switch surgery while the remaining 3% had laparoscopic gastric banding. Fourteen studies were rated as good quality, while 5 studies were rated as fair quality as per NIH tool for quality assessment. Pooled WPR with 95% confidence interval (CI) was 83.2% (79.6%, 86.3%), I2=0%. Funnel plot appeared asymmetric and publication bias was detected by Beg Mazumdar test (P=0.05). After adjusting for publication bias pooled WPR was 82.6% (78%, 86.4%). Pooled WPR for successful removal of stents was 94.9% (90.7%, 97.3%), I2=0%. Pooled WPR with 95% CI for rate of stent migration was 18.8% (13.3%, 25.9%) with significant heterogeneity. Conclusions: SEMS appear to be a favorable option for management of majority of patients with post bariatric surgery leaks. However, they have a significant risk of stent migration thus necessitating multiple endoscopies. Prospective studies evaluating the timing of stent placement and comparison with re-exploration surgery are needed.