HANY SHEHAB

A post-bariatric surgery leak is a rare but grave condition and remains every bariatric surgeon's nightmare. Endoscopic therapy with the insertion of self-expandable stents provides an effective minimally invasive approach for the management of leaks. Self-expandable stents, however, are still hampered by their tendency for migration and are not always well tolerated. Recently, double-pigtail stents have been proposed as an alternative endoscopic therapeutic modality. Both types of stents have been shown to be very effective in the management of leaks; however, most studies have pooled gastrointestinal leaks due to different etiologies together. In this article, we review the current status and foreseen innovations in gastrointestinal stenting for post-bariatric surgery leaks.

OBJECTIVE: The objectives of this study were to evaluate the impact of two X-ray repair cross complementing 1 (XRCC1) gene polymorphisms (Arg194Trp and Arg399Gln) on the risk of development of colorectal cancer (CRC) and to assess the expression levels of microRNA-21 (miR-21) in CRC patients.

MATERIALS AND METHODS: A case-control cross sectional study was conducted on 50 CRC patients and 50 cancer-free subjects. DNA and miR-21 were extracted from whole blood samples. The expression levels of the XRCC1 polymorphisms and miR-21 were assessed by real-time PCR in all subjects of the study.

RESULTS: Genotype analysis revealed a significant association between CRC risk and both the Arg194Trp genotype (OR=11.407, 95% CI=4.039-32.221, p<0.001) and the Arg399Gln genotype (OR=3.778, 95% CI= 1.6-8.919, p=0.002). The expression levels of circulating miR-21 were able to detect CRC cases significantly (p=0.022) with a sensitivity of 82% and a specificity of 56% (Area under the curve (AUC)=0.633) but were unable to distinguish between early and late cases (AJCC classification) (p=0.194).

CONCLUSION: The XRCC1 Arg194Trp and Arg399Gln polymorphisms both confer high susceptibility for the development of CRC. Circulating miR-21 expression levels are a potentially diagnostic non-invasive genetic marker of CRC.

BACKGROUND: Endoscopic stents are successful in the management of surgical leaks; however, stent migration remains a significant problem. In this study, we present our approach depending on a large bariatrics-specific stent (Mega stent) and over-the-scope clips in the management of post-bariatric surgery leaks.

METHODS: A retrospective analysis of all patients with post-bariatric surgery leaks treated at our institution using an approach reliant on Mega stents and over-the-scope clips was conducted. Potential factors associated with procedure success and occurrence of complications were also evaluated.

RESULTS: A total of 81 stents were inserted in 62 patients with post-bariatric surgery leaks, 46 sleeve gastrectomies (73%) and 16 Roux-en-Y gastric bypass (27%). Over-the-scope clips were applied in 29 patients (46%). Leak closure was achieved in 51 patients (82%). Median number of procedures per patient was 3 (range 2-8). Complications included the following: stent migration (11/62, 18%), intolerance necessitating premature removal (7/62, 11%), esophageal stricture (8/62, 13%), bleeding (4/62, 6%), perforation (4/62, 6%). One stent-induced mortality was encountered (bleeding). The presence of open surgery (vs laparoscopic) was significantly associated with the occurrence of stent-induced complications (p 0.002).

CONCLUSION: The approach combining Mega stents and over-the-scope clips is highly effective in the management of post-bariatric surgery leaks and is associated with a low rate of stent migration and a low number of procedures and stents per patient. Mega stents, however, should be used with great caution due to the significant morbidity associated with their use.