Standardization of the endoscopic approach in early bariatric leaks: an evidence-based clinical algorithm

Abstract

Gastrointestinal leaks remain a critical complication following bariatric surgery, associated with significant morbidity and mortality. Success in management has shifted toward a multidisciplinary approach where therapeutic endoscopy plays a central role. This study aims to standardize the endoscopic management of early leaks (postoperative days 3-7) through a clinical-technical algorithm based on current evidence. A comprehensive review of current literature (2020-2025) was conducted, analyzing 16 key studies focused on endoscopic interventions for leaks following laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB). The analysis included clinical success rates for primary closure (clips/suturing), diversion (stents), and internal drainage (pigtails/vacuum therapy). The evidence suggests a "window of opportunity" between days 3 and 7. For defects <10 mm in healthy tissue, primary closure with over-the-scope clips or endoscopic suturing is preferred. Larger defects (>10 mm) or those involving ischemic tissue require derivative therapy with mega-stents or vacuum-assisted closure (EVT). In RYGB, endoscopic suturing is the gold standard for anastomotic leaks, while in LSG, internal drainage via the EDEN protocol allows early enteral nutrition and reduces stent-related intolerance. Standardizing the endoscopic approach based on defect size and tissue biology is essential to optimize outcomes. Hemodynamically stable patients benefit from early endoscopic intervention, which reduces hospital stays and prevents the progression to chronic fistulas. The proposed algorithm provides a structured decision-making tool for the surgical team.