Table 1. Strategies in leak and fistula management.

References [23-50].

TTS: Through The Scope, OTS: Over The Scope, ALAOAGB: Anastomotic Leak After One Anastomosis Gastric Bypass, OAGB: One Anastomosis Gastric Bypass, SEM: Self Expandable Metal Stent, SEPS: Self Expandable Plastic Stent, SG: Sleeve Gastrectomy.

Strategy	Description	Advantages	Disadvantages	ALAOAGB
Intraoperative Leak Testing	Endoscopic or orogastric tube placement with air insufflation or colored dye to detect leaks intraoperatively	Supported for RYGB; may detect leaks early	Sensitivity and predictive value may be low; associated with increased postoperative leaks in some studies	Not specifically studied in OAGB
Endoscopic Clips	TTS and OTS clips used to close leaks	High success rates (up to 95%) in gastric surgery; OTS clips offer full-thickness closure	OTS clips difficult to remove; risk of fistula recurrence; limited use in chronic leaks	Utility in ALAOAGB not fully studied
Stents	SEPS and SEMS used to seal leaks and support fistula closure	SEPS easy to remove; less tissue hyperplasia; SEMS developed to reduce migration	High migration rates with SEPS; tissue hyperplasia with SEMS; complications with stent removal	Techniques not specifically studied in ALAOAGB
Endoscopic Suturing	Suturing leaks and fistulae using viable tissue; often requires de-epithelization	High success rates in managing perforations and fistulae	Requires expertise; lower success rates in anastomotic leaks (27%)	More research is needed to validate in ALAOAGB
Internal Drainage Systems	Pigtail stents across defects to internally drain fluid collections into the lumen promoting re-epithelization and closure	Higher efficacy compared to SEMS, sealants, and OTS clips; promotes earlier alimentation	May require multiple treatments; primarily studied in SG	Specific role in ALAOAGB yet to be studied
Endoscopic Vacuum Therapy	Negative pressure therapy within the lumen to promote re-epithelialization and closure	High success rates (90-100%) in leaks after bariatric surgery	Limited to experienced centers	Limited emphasis on ALAOAGB; more research needed
Tissue Sealants	Fibrin and cyanoacrylate glues used to seal leaks by promoting or imitating wound healing	Fibrin promotes physiological healing; cyanoacrylate is a strong adhesive with antibacterial properties	Variable success rates (36.5 to 75%); cyanoacrylate may cause tissue necrosis and inflammation	Success rates and efficacy need further studies in ALAOAGB