Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant

Endoluminal Vacuum Therapy as a Salvage Procedure for Difficult Anastomotic Leak Post Roux-en-Y Gastric Bypass

We present a case of a woman in her 60s, with a history of a gastric sleeve resection, over 50% excess body weight loss, and subsequent severe gastroesophageal reflux disease refractory to maximal medical therapy, who underwent a conversion of a sleeve gastrectomy to a Roux-en-Y gastric bypass with hiatal hernia repair. On postoperative day five, she was evaluated at our emergency department for vomiting and inability to tolerate oral intake. Imaging revealed a large retrocardiac hiatal hernia and extraluminal contrast extravasation. She was taken to the operating room after resuscitation, where the gastric pouch and roux limb were found to have significant edema with recurrence of the hernia. This was able to be reduced and a frank perforation was found at the posterior aspect of the anastomosis. A covered metal stent was placed by the gastroenterologist and drains were left in place.  In the ICU, nasojejunal feeds were stopped given suspicion of backflow with persistent leak. A decision was made to remove the stent and place an endoluminal vacuum (endoscopic vacuum-assisted wound closure [EVAC]). After three subsequent vacuum-sponge changes, the perforation was found to have healed. Patient was tolerating a diet on discharge. This case is an example of a complication where a multidisciplinary approach to a difficult leak resulted in recovery with the use of EVAC. We believe this is a valuable tool to have in our armamentarium for difficult-to-manage leaks.

Refractory gastrocutaneous fistula treated by two-stage surgery: a case report

BACKGROUND

Gastrocutaneous fistulas are a rare complication of enterocutaneous fistulas and can be caused by intestinal injury, infection, and anastomotic leakage. They are typically treated conservatively or endoscopically; however, for large or difficult-to-treat gastrocutaneous fistulas, surgical intervention is required. Herein, we present a case of a huge gastrocutaneous fistula that was successfully treated with a two-stage surgery performed using open abdomen management.

CASE PRESENTATION

A 61-year-old man with a perforated gastric ulcer underwent omental filling as an emergency surgery. Post-operative leakage led the development of a 10-cm gastrocutaneous fistula. He was transferred to our hospital for the treatment of gastrocutaneous fistula. Furthermore, nutritional therapy was administered for dehydration, electrolyte abnormalities, metabolic acidosis, and acute kidney injury due to the high-output nature of the fistula. Moreover, owing to the intraperitoneal severe adhesion and poor nutritional status, two-stage surgery was planned. In the first stage, extensive dissection of the adhesions, distal gastrectomy reconstruction with Roux-en-Y anastomosis, and jejunostomy were performed. Furthermore, open abdomen management was conducted to check for the presence of unexpected complications due to extensive dissection of the adhesion and anastomotic leakage. Subsequently, in the second stage of the surgery, abdominal closure was performed on the 9th day after gastrectomy.

CONCLUSION

Open abdomen management may be effective for huge gastrocutaneous fistulas with extensive adhesions that require surgical intervention.

Closure of Gastrocutaneous Fistula Following Bariatric Surgery: a Systematic Review

Gastrocutaneous fistula (GCF) is a devastating complication that can arise after bariatric and metabolic surgery (BMS). This systematic review examines the success rate of closure techniques of GCF. A systematic search was conducted across MEDLINE, Embase and Cochrane databases to identify studies which reported on closure techniques of GCF after BMS in adults. Thirty-three studies (n = 108 patients) were included. Seventeen different techniques were used to close GCF across all studies. The most popular were stents (n = 17), tissue sealants (n = 12) and over-the-scope clips (n = 11). Twenty-one studies used multiple techniques to attempt closure, including endoscopic vacuum therapy and revisional surgery. This systematic review demonstrates current practice focusing on endoscopic methods such as stents and over-the-scope clips, with relative success in closing GCF.

Development of a gastrocutaneous fistula from a marginal ulcer after repair of duodenal injury with pyloric exclusion

Introduction

Duodenal trauma is rare but can be associated with significant morbidity and mortality (Pandey et al., 2011). Adjunct procedures, such as pyloric exclusion, can be performed to assist in surgical repair of these injuries. However, pyloric exclusion can lead to severe long-term complications associated with significant morbidity that can be difficult to repair.

Case

A 35-year-old man with a history of duodenal trauma from a gunshot wound (GSW) status post pyloric exclusion and Roux-en-Y gastrojejunostomy presented to the Emergency Department (ED) with complaints of abdominal pain and leakage of food particles and fluid from an open wound around his surgical scar. Computed tomography (CT) scan on admission showed a tract extending from the gastrojejunostomy anastomosis to the skin representing a fistula. Esophago-gastro-duodenoscopy (EGD) reconfirmed a large marginal ulcer that had fistulized to the skin. After nutritional repletion, the patient was taken to the operating room (OR) for takedown of the enterocutaneous fistula and Roux-en-Y gastrojejunostomy, closure of gastrostomy and enterotomy, pyloroplasty and feeding jejunostomy tube placement. The patient was re-admitted after discharge with abdominal pain, vomiting and early satiety. EGD showed gastric outlet obstruction and severe pyloric stenosis which was managed with endoscopic balloon dilation.

Conclusion

This case represents the severe and potentially life-threatening complications that may occur after pyloric exclusion with Roux-en-Y gastrojejunostomy. Gastrojejunostomies are prone to marginal ulceration which can perforate if not adequately treated. Free perforations cause peritonitis, but if the perforation is contained it can erode through the abdominal wall creating the rare complication of a gastrocutaneous fistula. Even after restoration of normal anatomy with a pyloroplasty, patients may suffer additional complications such as pyloric stenosis requiring continued intervention.

Endoscopic Salvage of Gastrointestinal Anastomosis Leaks—Past, Present, and Future—A Narrated Review

Background: Anastomotic leakage, which is defined as a defect in the integrity of a surgical join between two hollow viscera leading to communication between the intraluminal and extraluminal compartments, continues to be of high incidence and one of the most feared complications following gastrointestinal surgery, with a significant potential for a fatal outcome. Surgical options for management are limited and carry a high risk of morbidity and mortality; thus, surgeons are urged to look for alternative options which are minimally invasive, repeatable, non-operative, and do not require general anesthesia. Methods: A narrative review of the international literature took place, including PubMed, Scopus, and Google Scholar, utilizing specific search terms such as “Digestive Surgery AND Anastomotic Leakage OR leak OR dehiscence”. Results: In the present review, we try to describe and analyze the pros and cons of the various endoscopic techniques: from the very first (and still available), fibrin gluing, to endoclip and over-the-scope clip positioning, stent insertion, and the latest suturing and endoluminal vacuum devices. Finally, alongside efforts to improve the existing techniques, we consider stem cell application as well as non-endoscopic, and even endoscopic, attempts at intraluminal microbiome modification, which should ultimately intervene pre-emptively, rather than therapeutically, to prevent leaks. Conclusions: In the last three decades, this search for an ideal device for closure, which must be safe, easy to deploy, inexpensive, robust, effect rapid and stable closure of even large defects, and have a low complication rate, has led to the proposal and application of a number of different endoscopic devices and techniques. However, to date, there is no consensus as to the best. The literature contains reports of only small studies and no randomized trials, failing to take into account both the heterogeneity of leaks and their different anatomical sites.

Treatment of Persistent Large Gastrocutaneous Fistulas After Bariatric Surgery: Preliminary Experience with Endoscopic Kehr's T-Tube Placement

PURPOSE

Post-bariatric surgery gastrocutaneous fistula is a chronic leak with an incidence of 1.7 to 4.0% and no standardized management. A large gastrocutaneous fistula (LGCF) is not indicated for treatment with pigtail drains. We aimed to evaluate results of a novel treatment using endoscopic Kehr's T-tube placement.

METHODS

Only patients with a postoperative LGCF duration of > 10 days and a flow rate of > 50 cc by external drainage after revisional surgery for sepsis were included. Endoscopic placement of Kehr's T-tube was performed. Patients had been reoperated with wash and drainage for severe sepsis after initial bariatric surgery in which no fistula had been discovered. Patients not reoperated, or with a fistula requiring intraoperative Kehr's T-tube placement, or a pigtail drain were excluded. Primary outcomes were endoscopic characteristics and results (LGCF closure rate, Kehr T-tube retention time, etc.).

RESULTS

The study group included 12 women, 2 men; body mass index 43.1 ± 4.5 kg/m2. Interventions were SG (7), RYGB (2), OAGB (4), and SADI-S (1). Endoscopic assessment was carried out after a mean of 33.2 ± 44.3 days after the bariatric procedure. The mean fistula orifice diameter was 2.0 ± 0.9 cm. Kehr's T-tube was positioned at a mean 51.5 ± 54.8 days after the bariatric procedure. T-tube tolerance was excellent. Mean additional days: hospitalization, 34.4 ± 27.0; T-tube retention, 86.4 ± 73.1; fistula healing, 139.9 ± 111.5, LGCF closure rate, 92.9%.

COMPLICATIONS

1 pulmonary embolism, 2 T-tube migrations,1 drain-path bleed, 1 skin abscess. No mortality.

CONCLUSIONS

Endoscopic Kehr's T-tube placement was successful in closing persistent post-bariatric surgery LGCF in 92.9% of patients.

Endoscopic internal drainage using transmural double-pigtail stents in leaks following upper gastrointestinal tract surgery

INTRODUCTION

different endoscopic procedures have been proposed for the management of surgical leaks. Endoscopic internal drainage using trans-fistulary double-pigtail plastic stents has emerged as an alternative strategy, especially in fistulae presenting after laparoscopic gastric sleeve.

METHODS

a retrospective case series was performed at a single tertiary care center including all upper gastrointestinal post-surgical leaks primarily managed with endoscopic trans-fistulary insertion of double-pigtail plastic stents. Clinical success was defined as the absence of extravasation of oral radiographic contrast and radiological resolution of the collection with adequate oral intake Results: nine patients were included, six (66.6 %) females with a median age of 52.6 years (IQR 47-60). Five cases presented after laparoscopic gastric sleeve, two cases after distal esophagectomies, one after a Roux-en-Y gastric bypass and another one after a pancreaticoduodenectomy. Fistulae measured < 10 mm in five patients (55.6 %) and 10-20 mm in four patients (44.4 %). Six were early leaks. Technical and clinical success was achieved in nine (100 %) and seven (77.8 %) cases, respectively. Seven (77.8 %) patients required ≤ 3 endoscopic procedures. The median hospital stay after the first endoscopic procedure was 12 days (IQR 6.5-17.5 days), while the overall median time until leak healing was 118.5 days (IQR 84.5-170). One patient with a post-esophagectomy intrathoracic leak developed an esophageal-tracheal fistula 37 days after stent deployment.

CONCLUSIONS

our results support the use of endoscopic internal drainage in postsurgical abdominal leaks, regardless of the type of surgery. Although only two patients with intrathoracic dehiscence were included.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis

Background

Endoscopic techniques have become the first-line therapy in bariatric surgery-related complications such as leaks and fistulas. We performed a systematic review and meta-analysis on the effectiveness of self-expandable stents, clipping, and tissue sealants in closing of post-bariatric surgery leak/fistula.

Methods

A systematic literature search of the Medline/Scopus databases was performed to identify full-text articles published up to February 2019 on the use of self-expandable stents, clipping, or tissue sealants as primary endoscopic strategies used for leak/fistula closure. Meta-analysis of studies reporting stents was performed with the PRISMA guidelines.

Results

Data concerning the efficacy of self-expanding stents in the treatment of leaks/fistulas after bariatric surgery were extracted from 40 studies (493 patients). The overall proportion of successful leak/fistula closure was 92% (95% CI, 90–95%). The overall proportion of stent migration was 23% (95% CI, 19–28%). Seventeen papers (98 patients) reported the use of clipping: the over-the-scope clips (OTSC) system was used in 85 patients with a successful closure rate of 67.1% and a few complications (migration, stenosis, tear). The successful fistula/leak closure using other than OTSC types was achieved in 69.2% of patients. In 10 case series (63 patients), fibrin glue alone was used with a 92.8–100% success rate of fistula closure that usually required repeated sessions at scheduled intervals. The complications of fibrin glue applications were reported in only one study and included pain and fever in 12.5% of patients.

Conclusions

Endoscopic techniques are effective for management of post-bariatric leaks and fistulas in properly selected patients.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07471-1) contains supplementary material, which is available to authorized users.

Endoscopic Closure of Gastro-gastric Fistula After Gastric Bypass: a Technically Feasible Procedure but Associated with Low Success Rate

BACKGROUND

Gastro-gastric fistulas (GGF) are reported to be as high as 12% after gastric bypass for treatment of morbid obesity. While different endoscopic methods are described, the management traditionally consists of surgical revision with high associated morbidity. The aim of the study was to assess feasibility, safety and success rate of endoscopic closure using an endoscopic suturing device.

METHODS

From January 2016 to March 2018, we reviewed the electronic records of all patients undergoing endoscopic closure of a GGF with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA). Demographic details, procedure details, and outcome variables were recorded.

RESULTS

A total of six patients (M:F = 5:1) underwent endoscopic fistula closure. Five patients (83.3%) had a prior banded gastric bypass (with subsequent band removal). The median number of prior abdominal surgeries was 3, the mean time from bypass to endoscopic fistula closure was 5 years (range 1.1-10.4). While immediate complete endoscopic fistula closure was possible in 10 of 12 attempts in those six patients (83%), all patients had recurrent (persistent) fistulas at follow-up. After a mean follow-up time of 12 months, 83.3% had further laparoscopic converted to open (n = 2) or laparoscopic (n = 3) revisions with complete fistula closure. One patient is refusing further intervention.

CONCLUSION

Endoscopic gastro-gastric fistula closure with an endoscopic suturing device is feasible and safe. Unfortunately, due to the nature of gastro-gastric fistulas, permanent successful closure is rare. Therefore, the approach should be reserved for patients in whom a laparoscopic or open surgical attempt is impossible due to prior abdominal revisions.

Continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration for the management of postoperative high-output enterocutaneous fistulas: Three case reports and literature review

INTRODUCTION

Enterocutaneous fistula is considered one of the most serious complications in general surgery and is associated with high morbidity and mortality. Although various treatments are reported to have varying success, high-output enterocutaneous fistulas (output over 500 ml/day) continue to be associated with high mortality, and few papers on this topic exist in the literature. The aim of this study is to describe an effective multidisciplinary treatment method for postoperative high-output enterocutaneous fistula and discuss the clinical development of the therapeutic strategy.

PATIENT CONCERNS

Three patients suffered high-output enterocutaneous fistulas, in which case 1 presented with duodenal fistula, case 2 with ileal fistula, and case 3 with small bowel fistula.

DIAGNOSIS

All 3 cases were diagnosed with high-output enterocutaneous fistulas by drainage of intestinal contents.

INTERVENTIONS

With the exception of routine treatment including fluid resuscitation, correction of the electrolyte balance, control of infection, and optimal nutrition, all the cases accepted continuous irrigation and suction with triple-cavity drainage tubes in combination with sequential somatostatin-somatotropin administration were given. With regard to establishing effective drainage, the triple-cavity tube placement was performed by insertion through the initial drainage channel in case 1, percutaneous puncture with dilation by graduated dilators in case 2, and tract reconstruction in case 3. The technical details of the approach are described and clinical characteristics including fistula location, defect size, output volume, approach of triple-cavity tube placement, length of fistula tract, somatostatin and somatotropin administration time, and fistula healing time were recorded and compared. In addition, other various techniques reported in the literature are reviewed and discussed.

OUTCOMES

All the patients were cured by the multidisciplinary treatments and were followed up without fistula recurrence and other relevant complications at 1 week, 1 month, and 3 months after the treatments.

CONCLUSION

The strategy involving continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration may be a safe and effective alternative treatment for postoperative high-output enterocutaneous fistula and a more practical method that is easy to execute to manage this problem. Long-term studies, involving more patients, are still necessary to confirm this suggestion.

Trends in Utilization and Relative Complication Rates of Bariatric Procedures

BACKGROUND

Laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding have been popular alternatives to laparoscopic Roux-en-Y gastric bypass due to their technical ease and lower complication rates. Comprehensive longitudinal data are necessary to guide selection of the appropriate bariatric procedures for individual patients.

METHODS

We used the Truven Heath Analytics MarketScan® database between 2000 and 2015 to identify patients undergoing bariatric surgery. Kaplan-Meier and Cox proportional hazard regression analyses were performed to compare complication rates between laparoscopic gastric bypass and laparoscopic sleeve gastrectomy, as well as between laparoscopic gastric bypass and laparoscopic adjustable gastric banding.

RESULTS

256,830 individuals met search criteria. By 2015, laparoscopic sleeve gastrectomy was the most commonly performed bariatric procedure followed by laparoscopic gastric bypass and then laparoscopic adjustable gastric banding. Overall, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding had fewer complications relative to laparoscopic gastric bypass with the exceptions of heartburn, gastritis, and portal vein thrombosis following sleeve gastrectomy and heartburn and dysphagia following adjustable gastric banding.

CONCLUSION

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric procedure in the USA. It is reassuring that its overall postoperative complication rates are lower relative to laparoscopic gastric bypass.

An unusual presentation of gastric fistula following peptic perforation repair: A case report

•

Late onset Gastrocutaneous fistulas are rare following the peptic perforation repair.

•

A non-healing burst abdominal wound should be thoroughly investigated. It can be because of an underlying fistula.

•

CT fistulogram is the investigation of choice to confirm the diagnosis.

•

Operative intervention is difficult but the only method of cure in most of the circumstances.

Introduction

Peptic perforation repair is a common stomach surgery. This surgery has not been associated with delayed onset gastrocutaneous fistula formation. However such a complication has been reported following a variety of other stomach surgeries. We are reporting this case as it is a rare complication. Also its diagnosis and management is challenging.

Case summary

We are presenting a case of peptic perforation repair where burst abdomen happened in the immediate post-operative period. The patient was put on conservative management. He responded well to it but his abdominal wound was not healing. After a wait of four months the wound was covered with a skin graft. The graft uptake was satisfactory but a discharging ulcer appeared on it. This condition persisted for one month. Finally a computed tomography Fistulogram (CT Fistulogram) was performed. It revealed an underlying complex gastric fistula. A repeat surgery was performed.

Conclusion

A gastrocutaneous fistula diagnosed at sixth month following the peptic perforation repair and causing minimal discomfort to the patient is a rare presentation. The abdominal wound following the surgery was possibly not healing because of the underlying fistula.

Sleeve Gastrectomy: Surgical Tips

The vertical sleeve gastrectomy is a bariatric procedure that was originally described as the initial step in the biliopancreatic diversion. It demonstrated effectiveness in weight loss as a single procedure, and the laparoscopic vertical sleeve gastrectomy, as a stand-alone procedure, is now the most commonly performed bariatric surgery worldwide. Due to its relative technical ease and long-term data that have established its durability in treating obesity and its related comorbid conditions, the sleeve gastrectomy has grown in popularity among patients and surgeons. While there are variations in the technical aspects of performing a laparoscopic sleeve gastrectomy, key steps must be undertaken to produce safe and effective outcomes. This article reviews the indications for bariatric surgery, patient selection, surgical technique and tips, perioperative care and complications after sleeve gastrectomy.

Internal endoscopic drainage as first line or second line treatment in case of postsleeve gastrectomy fistulas

BACKGROUND AND STUDY AIMS

Management of post-sleeve gastrectomy fistulas (PSGF) recently has evolved, resulting in prioritization of internal endoscopic drainage (IED). We report our experience with the technique in a tertiary center.

PATIENTS AND METHODS

 This was a single-center, retrospective study of 44 patients whose PSGF was managed with IED, comparing two periods: after 2013 (Group 1; n = 22) when IED was used in first line and before 2013 (Group 2; n = 22) when IED was applied in second line. Demographic data, pre-endoscopic management, characteristics of fistulas, therapeutic modalities and outcomes were recorded and compared between the two groups. The primary endpoint was IED efficacy; the secondary endpoint was a comparison of outcomes depending on the timing of IED in the management strategy.

RESULTS

 The groups were matched in gender (16 female, 16 male), mean age (43 years old), severity of fistula, delay before treatment, and exposure to previous endoscopic or surgical treatments. The overall efficacy rate was 84 % (37/44): 86 % in Group 1 and 82 % in Group 2 (NS). There was one death and one patient who underwent surgery. The median time to healing was 226 ± 750 days (Group 1) vs. 305 ± 300 days (Group 2) (NS), with a median number of endoscopies of 3 ± 6 vs . 4.5 ± 2.4 (NS). There were no differences in number of nasocavity drains and double pigtail stents (DPS), but significantly more metallic stents, complications, and secondary strictures were seen in Group 2.

CONCLUSION

 IED for management of PSGF is effective in more than 80 % of cases whenever it is used during the therapeutic strategy. This approach should be favored when possible.

Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality.

OBJECTIVES

To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG.

SETTING

University hospital, Israel.

METHODS

Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m²) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage.

RESULTS

There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46).

CONCLUSIONS

Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.

Endoscopic Treatment of Diverse Complications Caused by Laparoscopic Adjustable Gastric Banding: A Study in Eastern Asia

Background/Aims

The use of laparoscopic adjustable gastric banding (LAGB) is increasing proportionally with the obesity epidemic. However, some postoperative complications have been highlighted as major problems associated with LAGB. There is no consensus concerning the endoscopic management of these adverse events. The aim of this study was to retrospectively review the feasibility and effectiveness of endoscopic treatment for LAGB complications.

Methods

We retrospectively evaluated 352 patients who underwent LAGB between 2011 and 2015. LAGB-associated complications developed in 26 patients (7.4%). This study involved six patients (1.7%) who received endoscopic treatment.

Results

Types of LAGB-induced complications in our series included intragastric migration (n=3), gastric leaks (n=2), and gastric fistulas (n=1). The endoscopic treatment of these complications was successful in four of the six patients. Endoscopic band removal was successful in two patients. All gastric leaks were successfully closed via an endoscopic procedure. In two cases (intragastric migration and gastric fistula), endoscopic treatment was not sufficient, and surgery was performed.

Conclusions

Endoscopic procedures afforded acceptable treatment of band migration and gastric leaks after LAGB. However, the results were poor in patients with gastric fistula.

Role of Percutaneous Glue Treatment After Persisting Leak After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Over the years, many treatment modes have been attempted for gastrocutaneous fistula (GCF) after laparoscopic sleeve gastrectomy (LSG). Minimally invasive techniques for GCF treatment include stent placement and radiological percutaneous glue treatment (GT).

MATERIAL AND METHOD

Ten patients underwent a radiological acrylate mixed with contrast medium GT combined or not with other treatment strategies such as relaparoscopy, ultrasound, or computerized tomography scan (CT scan)-guided drain and endoscopic stent placement.

RESULTS

Ten patients (mean age 47.1 years, range 64-29) were treated by percutaneous injection of glue after LSG leak. Body mass index (BMI) was 42.2 kg/m(2) ± 6.7 at the time of LSG surgery. Mean time between LSG and leak diagnosis was 12 days (range 4-31 days). GT was only effective when performed after endoscopic stent placement (80 % resolution). With this regimen, five patients required a laparoscopic Roux limb placement. All fistulas eventually healed a mean of 75 days (range 29-293 days) after GCF diagnosis.

CONCLUSIONS

Percutaneous glue treatment alone does not seem to provide adequate results. Stenting previous to the glue treatment allows for better results.

Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results

Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.

Treatment Options in Gastrointestinal Cutaneous Fistulas

Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.

Over-the-scope clip placement for closure of gastrointestinal fistula, postoperative leaks and refractory gastrointestinal bleed

INTRODUCTION

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application.

METHODS

Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy's lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another.

RESULTS

All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2 months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously.

CONCLUSION

OTSC provided safe and successful closure in a number of settings.

Laparoscopic Transgastric Repair of a Gastrogastric Fistula After Gastric Bypass

Gastrogastric fistulas are an uncommon complication following laparoscopic Roux-Y gastric bypass surgery (LRYGB) and may be caused by staple-line dehiscence or leak. Described here is a novel technique to treat these fistulae via a laparoscopic transgastric approach and closure of the fistulous tract with an Endo Stitch™ device. The 33-year-old patient, post LRYGB in 2002, with documented gastrogastric fistula, had failed non-operative management. A transoral endoscope was passed into the cephalad portion of the gastrogastric fistula; a glidewire was passed from the gastric pouch into the gastric remnant. Laparoscopically, 2 gastrotomies were made and a “pneumogastrium” created with carbon dioxide. Under direct, transgastric visualization, the distal portion of the gastrogastric fistula was closed using an Endo Stitch™ device. This technique is safe and reproducible when performed by an experienced laparoscopic surgeon and could be modified for other scenarios requiring alternate access to the stomach.

Endoscopic closure of persistent gastrocutaneous fistulae, after percutaneous endoscopic gastrostomy (PEG) tube placement, using the over-the-scope-clip system

OBJECTIVES

The Over-The-Scope-Clip (OTSC) has had an evolving role in endoscopic closure of gastrointestinal wall defects, in hemostasis of primary or postinterventional bleeding, and approximation of postbariatric surgery defects. Rapid and effective closure of gastrocutaneous (GC) fistulae using this device has been recently described in the literature. The aim of this study was to evaluate the technical feasibility, efficacy and safety of OTSC as an effective tool in the management of persistent GC fistulae secondary to a complication of percutaneous endoscopic gastrostomy (PEG) tube placement.

METHOD

In this multicenter prospective observational study, we describe our experience with OTSC in the closure of persistent GC fistulas secondary to PEG tube placement. Patients with GC fistulas were sequentially enrolled with a mean age of 84 years. Primary treatment outcome was the immediate successful closure of GC fistula and resolution of leak. Secondary outcome was no recurrence of the fistula and leaks on follow up.

RESULTS

A total of 10 patients were enrolled over the study period. Mean age was 84.4 ± 8.75 years. The primary treatment outcome was achieved in all the patients undergoing this intervention. Secondary outcome was observed in 9/10 (90%) subjects. No procedural complications were reported. Larger fistulae (>2.5 cm) and those with significant fibrosis were more difficult to close with the OTSC system. The mean follow-up time after OTSC application was 43.7 ± 20.57 days. A limitation of this study was that there was no control group.

CONCLUSIONS

OTSC application is a safe and effective endoscopic approach for the closure of persistent GC fistulae secondary to a complication of PEG tube placement.

Tissue sealants in endoscopic applications for anastomotic leakage during a 25-year period

BACKGROUND

Anastomotic leakage after gastrointestinal operation is a complication difficult to manage because conservative therapy and/or reoperation may be unsuccessful and carry the risk of increased morbidity and mortality. The endoscopic use of tissue sealants appears to be a promising alternative to avoid operation.

METHOD

We present conclusively our 25-year experience with tissue sealing in a series of 63 patients referred after gastrointestinal anastomosis leakage; 48 of the upper and 15 of the lower gastrointestinal tract, experiencing a drainage volume ranging 50-2,400 mL.

RESULTS

Tissue glue was applied orally in 37, anally in 10, through the fistula tract in 8, and through a combination of approximation routes in another 8 cases. Biological glue (fibrin) was used in 47, cyanoacrylate in 8, and both glue types in another 8 patients. The total volume of fibrin applied was 2-36 mL, in a median of four sessions, 0.5-4 mL for cyanoacrylate, in a median of two sessions, and, whenever a combination of glues was used, a volume of 12-40 mL of fibrin plus 1-4 mL of cyanoacrylate, in a median of nine sessions. The median hospital stay after initiation of gluing was 14 days (range 8-32). The clinical and technical success rate was 96.8% (61 of 63 patients).

CONCLUSION

Tissue glue appears to be a valuable clinical tool that would prevent further operative interventions and the associated morbidity and mortality after a gastrointestinal anastomosis dehiscence. However, it must be borne in mind that repeated sessions and large volumes of sealants are necessary in many cases.

Treatment of foregut fistula with biologic plugs

INTRODUCTION

Enteric fistulas are a recognised complication of various diseases and surgical interventions. Non-operative medical management will result in closure of 60-70% of all fistulas over a six- to eight-week period, those that fail non-operative management will require operative intervention if they are to close. We present a series of upper gastrointestinal fistula managed with endoscopic intervention and insertion of biological fistula plug over a 3-year period across three Hospitals, both public and private, in Western Australia.

METHODS

Over a three-year period, 14 patients were referred for treatment of acute or persistent foregut fistulas. All fistulas were managed with endoscopic intervention and insertion of a porcine small intestine sub-mucosa plug (Biodesign (®) Cook medical Inc., Bloomington, IN, USA). No patients with fistula were excluded. Data were collected on patient demographics and underlying diagnosis. The biological plugs were deployed using three different endoscopic techniques (direct deployment via the endoscope, catheter-assisted endoscopic deployment, or a pull through via a guide wire using a rendezvous technique).

RESULTS

Fourteen patients with foregut fistula were treated using biological plugs. The age of the fistulas treated ranged from 14 days to 3 years. The fistulas were predominantly gastric in origin (eight cases). Three oesophageal, one gastro-pleural-bronchial, and two jejunal fistulas were also managed using this technique. Of the 14 fistulas treated using this method, 13 resolved following the treatment. Median time to closure of the fistula was 2 days (range 1-120 days). Three patients required more than one intervention to complete closure.

CONCLUSION

Biological plugs offer a further option for management of the traditionally difficult foregut fistula, without major morbidity associated with other treatment modalities. It is limited to the ability to deploy the plug endoscopically.

Endoscopic therapies for leaks and fistulas after bariatric surgery

Bariatric surgery is the most effective treatment for the medical comorbidities associated with morbid obesity. Though uncommon, staple line or anastomotic leaks after bariatric surgery are highly morbid events and challenging to treat. In selected patients without severe sepsis or distant pollution, endoscopic transluminal peritoneal drainage may provide source control. For leaks within 3 days of surgery, endoscopic stenting does not appear to speed closure but does permit oral nutrition. In uncomplicated situations, the risk of migration and resulting complications of enteric stents appear to overshadow the benefits. Initial treatment failures and leaks presenting more than 48 hours after surgery respond to enteric diversion by endoscopic stenting. Occlusion of the leak by injection of fibrin glue also shows promise; however, these case series are limited to a small number of patients. Endoclips may work best to occlude leaks and close fistulas if the epithelium is debrided. As suturing technology improves, direct internal closure of fistulas may prove feasible. Therapeutic endoscopy offers several technologies that can assist in the closure of early leaks and that are essential to the treatment of late leaks and fistulas after bariatric surgery.

Clinical outcomes of endoscopic and surgical management for postoperative upper gastrointestinal leakage

BACKGROUND

The purpose of this study was to evaluate the safety and efficacy of endoscopic therapy, an alternative and less invasive modality for the management of leakage after gastrectomy.

METHODS

An electronic database of 35 patients with anastomotic leaks after surgery for stomach cancer that were treated with either an endoscopic procedure or surgery between January 2004 and March 2012 was reviewed. The success rates and safety of both modalities were evaluated.

RESULTS

Endoscopic treatment was performed in 20 patients and surgical treatment in 15 patients. The median time interval between the primary surgery and diagnosis of leakage was 8.0 days (interquartile range, 5.0-14.0 days). Of the 20 patients with endoscopic treatment, technical success was achieved in 19 patients (95 %) with resulting clinical success achieved in all of these 19 patients (100 %). One patient with failed endoscopic management went on to receive surgery. There were no cases of leakage-related deaths after endoscopic treatment. Of the 15 patients with surgical treatment, 5 died due to sepsis, bleeding, or hospital-acquired pneumonia. For diagnosis of leakage, 17 patients from the endoscopy group underwent computed tomography (CT) scanning, which revealed leakages in 3 patients (17.6 %) and occult leakages were subsequently defined at fluoroscopy in all 20 patients. Seven of twelve patients (58.3 %) from the surgical group had leakages diagnosed by CT scan.

CONCLUSIONS

Endoscopic treatment can be considered a valuable option for the management of postoperative anastomotic leakage with a high degree of technical feasibility and safety, particularly for leakages that are not excessively large.

Stent treatment for fistula after obesity surgery: results in 47 consecutive patients

BACKGROUND

Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery.

METHODS

We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications.

RESULTS

There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment.

CONCLUSIONS

Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.

Radiographic and endoscopic diagnosis and treatment of enterocutaneous fistulas

The management of enterocutaneous fistulas continues to be a challenging postoperative complication. Understanding the anatomy of the fistula optimizes its evaluation and management. Diagnostic radiology has always played an important role in this task. The use of plain radiography with contrasted studies and fistulograms is well documented in the earliest investigations of fistulas and they continue to be helpful techniques. The imaging techniques have evolved rapidly over the past 15 years with the introduction of cross-sectional imaging, ultrasound and endoscopy. The purpose of this chapter is to review both the diagnostic and therapeutic roles of fistulograms, small bowel follow-through, computed tomography, magnetic resonance imaging, ultrasound, and endoscopy in the setting of acquired enterocutaneous fistulas.

Endoscopic management of gastrogastric fistulae does not increase complications at bariatric revision surgery

BACKGROUND

Gastrogastric fistula (GGF) is a challenging complication of primary obesity surgery that often leads to revision surgery. The impact of prior endoscopic intervention on subsequent surgical revisional outcomes remains unknown. We present the largest series of Roux-en-Y gastric bypass GGF with subsequent surgical revision of fistulae to date.

METHODS

A database of bariatric surgical revisions performed at a single institution was collected. The cohort was divided between patients with and without attempted endoscopic fistula closure prior to surgical revision. Thirty-day morbidity and mortality was the primary outcome.

RESULTS

Thirty-five cases of revision were performed for GGF. Of the 35 cases, 22 patients had attempted endoscopic closure prior to surgical revision while 13 patients went directly to surgical revision. In the endoscopy group, two minor complications and seven major complications occurred (total 9 of 22; 40.9%). In the surgery only group, three minor complications and three major complications occurred (total 6 of 13; 46.1%). No deaths occurred.

CONCLUSION

Prior attempts at endoscopic fistula closure do not lead to increased surgical complications at the time of surgical revision.

Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity

GOAL

Laparoscopic sleeve gastrectomy (LSG) is performed in certain circumstances after failure of gastric banding. The goal of this study was to evaluate the impact of first-line gastric banding on the morbidity associated with secondary LSG for obesity.

PATIENTS AND METHODS

The case records of 102 consecutive patients undergoing LSG were studied retrospectively. The technique of LSG was standardized. Two groups were compared: one with patients having undergone LSG after first-line gastric banding (n = 31) and the second, with patients having undergone first-line LSG (n = 71). Endpoints were overall morbidity and intra/postoperative complications including gastric leaks consecutive to staple line disruption as well as other septic or hemorrhagic complications. Multivariable analysis was performed to detect independent risk factors for morbidity.

RESULTS

Overall morbidity was significantly higher in patients having undergone LSG after first-line gastric banding compared with those undergoing first-line LSG (32.2% vs. 7%, P = 0.002). Gastric leaks secondary to staple line disruption also occurred statistically significantly more often in patients with first-line gastric banding (16.1% vs. 2.8%, P = 0.043). Waiting 6 months between gastric band removal and performing LSG did not prevent the increased morbidity compared with first-line LSG. Multivariable analysis revealed that among the factors analyzed (age, gender, comorbidity, body mass index, surgeon, first-line gastric banding), the only independent risk factor for staple line disruption was first-line gastric banding with an odds ratio = 6.6 (95% confidence interval = [1.2-36.3]).

CONCLUSION

Undergoing first-line gastric banding increases the risk of complications after secondary LSG. We recommend that patients who undergo LSG after a first-line gastric banding should be warned of the increased risks of morbidity or, alternatively, that LSG be performed preferentially as the initial procedure.

Endoscopic treatment of a gastrocutaneous fistula using the over-the-scope-clip system: a case report

The over-the-scope-clip (OTSC; Ovesco Endoscopy GmbH, Tuebingen, Germany) system is a newly designed method for the mechanical compression of large areas in the gastrointestinal tract. So far, indications for OTSC application are hemostasis of primary or postinterventional bleeding, closure of iatrogenic full-thickness or covered perforations. Recently closure of gastrointestinal tract fistulas using this device has been described. A 44-year-old man developed a gastrocutaneous fistula after surgical treatment for a perforated gastric ulcer. We describe the successful endoscopic closure of the fistula using the OTSC system. The patient's clinical followup was uneventful. Fistula closure was successfully implemented as it was documented by imaging and endoscopic examinations performed on the 2nd day and 6th week after the application of the clip. Endoscopic application of the OTSC device was safe and effective for the treatment of a gastrocutaneous fistula.

Endoscopic management of common bariatric surgical complications

The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation. Endoscopists caring for these patients should become familiar with post-bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal/extra-luminal findings, and endoscopic management of common bariatric complications; this review addresses these issues. This review will discuss common presenting symptoms, luminal as well as extra-luminal findings and endoscopic management of common bariatric complications.

Revisional surgery after sleeve gastrectomy

INTRODUCTION

Worldwide, morbid obesity incidence has increased dramatically in the last decade and surgery is at this moment recognized as the only effective treatment with long-term sustained weight loss and resolution or significant improvement in comorbidities. Laparoscopic sleeve gastrectomy (LSG) was successfully carried out by several groups as a bridge to future laparoscopic bariatric procedures with acceptable weight loss and reduction in comorbidities. LSG is considered a safe procedure with sporadically reported complications, such as bleeding or leakage from the staple line, strictures, delayed gastric emptying, gastric dilatation and vomiting. The aim of this publication is to describe complications of this procedure analyze different treatments of these events especially the surgical ones, reporting the technical management based on our experience and on the literature.

MATERIAL AND METHODS

From March 2003 to December 2009, 294 patients underwent LSG in our Department. Complications are reported prospectively.

RESULTS

In our series 294 patients were operated and stapler line leak was observed in 11 patients (3.7%). The mean time from the first surgery up to the first reintervention was 15.6±22 days (2 to 78). Only 2 patients (0.68%) had to be operated owing to severe reflux related with the sleeve gastrectomy and the symptomatology was solved with the gastric bypass. Intraabdominal bleeding was observed in 7 patients (2.38%), being reoperated 3 (1.02%) of them. All patients were reoperated by laparoscopic approach and the bleeding vessel was identified in all of them. We identified 3 of 294 patients with strictures (1.02%). One of them was located in the gastroesophageal junction and the other 2 had a central location. The patient with high stenosis required endoscopic dilatation and the other 2 were resolved by a gastric bypass cutting the stomach proximal to the stricture. The global mortality was 0%. All of the patients were reoperated by laparoscopy.

CONCLUSION

LSG is a feasible bariatric procedure carried out increasingly in the last few years with low postoperative complications. Regardless, the knowledge of the potential complications associated to LSG and their management is crucial for patient's safety.

An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study

BACKGROUND

Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding.

OBJECTIVE

To assess a new, totally endoscopic strategy to manage anastomotic fistulas.

DESIGN

Prospective study.

SETTING

Tertiary-care university hospital.

PATIENTS

This study involved 27 consecutive patients from July 2007 to December 2009.

INTERVENTION

This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant.

MAIN OUTCOME MEASUREMENTS

Technical success, mortality and morbidity, migration of the stent.

RESULTS

Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient.

LIMITATIONS

Moderate sample size, nonrandomized study.

CONCLUSION

An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.

Endoscopic repair of small symptomatic gastrogastric fistulas after gastric bypass surgery: a single center experience

Gastrogastric fistula (GGF) is a known complication of gastric bypass surgery. Revisional surgery for GGF repair can be technically challenging. We describe our experience with endoscopic repair of small GGFs. A retrospective review was performed to identify patients in whom symptomatic GGF was repaired endoscopically at our institution between September 2004 and September 2008. At endoscopy, the fistulous margins were debrided using cold biopsy forceps or ablated using Argon Plasma Coagulation (APC). The fistula was then repaired with endoclips. Status of GGF repair was assessed intra-operatively, at 2 weeks by upper gastrointestinal (UGI) series, and at regular follow-up thereafter. GGF repair was attempted in eight female patients (mean age = 47 years). The average time interval between gastric bypass surgery and GGF presentation was 81 months. The presenting symptoms included nausea, vomiting, abdominal pain, and weight regain. The average duration of endoscopic procedure was 55 min. All GGFs were small (<20 mm). Endoscopic repair of GGF was successful intra-operatively in all patients. Two patients had failure of GGF repair at 2 weeks. Other two patients experienced recurrent symptoms after several weeks and had a delayed failure of GGF repair diagnosed by UGI series. Endoscopic repair has remained successful in four patients at 8-46 months follow-up. Endoscopic repair of small GGFs using endoclips is feasible. It must be considered as an option for management of small GGFs, given its safety, and ease of performance compared to revisional surgery.

Endoscopic Management of Drain Inclusion in the Gastric Pouch after Gastrojejunal Leakage after Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity (LRYGBP)

Background. Drain inclusion inside the gastric pouch is rare and can represent an important source of morbidity and mortality associated with laparocopic Roux-en-Y gastric bypass (LRYGBP). These leaks can become chronic and challenging. Surgical options are often unsuccessful. We present the endoscopic management of four patients with drain inclusion. Patients. All four obese morbidly patients underwent LRYGBP and presented a gastro-jejunal fistula after acute anastomotic leakage. During follow-up endoscopy the drain was found inside the gastric pouch. It was moved into the abdominal cavity. Fistula debit reduced significantly and closed. Results. Gastric leak closure in less than 24 hours was achieved in all, with complete resolution of symptoms. These patients benefited exclusively from endoscopic treatment. Conclusions. Endoscopy is useful and technically feasible in chronic fistulas. This procedure is a less invasive alternative to traditional surgical revision. Other therapeutic strategies can be used such as clips and fibrin glue. Drains should not be placed in contact with the anastomosis or stapled lines. Drain inclusion must be suspected when fistula debit suddenly arises. If so, endoscopy is indicated for diagnostic accuracy. Under endoscopy vision, the drain is gently removed from the gastric reservoir leading to sudden and complete resolution of the fistula.

Reduction of the closure time of postoperative enterocutaneous fistulas with fibrin sealant

AIM: To assess whether the use of fibrin sealant shortens the closure time of postoperative enterocutaneous fistulas (ECFs).

METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application directly through the external hole. Outcome variables included closure time, time to resume oral feeding and morbidity related to nutritional support.

RESULTS: There were no differences in mean age, fistula output, and follow-up. Closure-time for all patients of the study group was 12.5 ± 14.2 d and 32.5 ± 17.9 d for the control group (P < 0.001), and morbidity related to nutritional support was 8.6% and 42.5%, respectively (P < 0.01). In patients with colonic fistulas, complete closure occurred 23.5 ± 19.5 d after the first application of fibrin glue, and spontaneous closure was observed after 36.2 ± 22.8 d in the control group (P = 0.36). Recurrences were observed in 2 patients because of residual disease. One patient of each group died during follow-up as a consequence of septic complications related to parenteral nutrition.

CONCLUSION: Closure time was significantly reduced with the use of fibrin sealant, and oral feeding was resumed faster. We suggest the use of fibrin sealant for the management of stable enterocutaneous fistulas.

Endoscopic repair of gastrogastric fistula after Roux-en-Y gastric bypass: a less-invasive approach

BACKGROUND

Gastrogastric fistulas (GGFs) are a well-known complication of Roux-en-Y gastric bypass. Surgical repair of such fistulas is technically difficult, with significant associated morbidity. The aim of the present study was to evaluate the efficacy of endoscopic GGF closure at a university hospital in the United States.

METHODS

Patients with Roux-en-Y gastric bypass and confirmed GGFs on esophagogastroduodenoscopy or barium study. Endoscopic repair was performed with the EndoCinch suturing system (group 1) or clips (group 2). All patients were followed up in the outpatient clinic or interviewed by telephone at 1, 6, and 18 months after the procedure, then as indicated by symptoms.

RESULTS

A total of 95 patients were included in the present series (group 1, n = 71, 75%; group 2, n = 24, 25%). The mean GGF size was significantly larger in group 1 than in group 2 (14.5 +/- 8.7 versus 7.7 +/- 6, P = .01). An average of 2.2 sutures or 3 clips (range 2-7) was used. Complete initial GGF closure was achieved in 90 patients (95%), with reopening in 59 (65%) an average of 177 +/- 202 days. The average follow-up was 395 +/- 49 days, with 22 patients lost to follow-up. Two significant complications were reported (bleeding and an esophageal tear). None of the GGFs with an initial size >20 mm remained closed during the follow-up period compared with 10 (32%) of the 31 fistulas <or=10 mm in diameter remained closed.

CONCLUSION

Peroral endoscopic repair of postbariatric GGFs is technically feasible and safe but with limited durability. The fistula size predicted for long-term outcomes, with the best results seen in fistulas <or=10 mm in diameter.