EUS-guided drainage with LAMS to treat a refractory micro-fistula after sleeve gastrectomy: Widen the fistula if you cannot seal it

A 26-year-old female with a history of sleeve gastrectomy presented with a leak and underwent surgical drainage. She had recurrent sepsis 3 days later due to a perigastric abscess.

An esophageal stent (23 mm × 15 cm) was deployed [1] [2] [3] and sutured to the wall.

The abscess was aspirated percutaneously. A percutaneous drain could not be placed due to a difficult location. She was discharged.

Three weeks later, the patient had a recurrent abscess ([Fig. 1]). The stent was removed and no patent orifice was identified. Pneumatic dilation of narrowing at the incisura angularis [1] [2] [3] was performed (30-mm balloon, PSI 15). Endoscopic ultrasound (EUS)-guided drainage using a double pigtail stent was performed ([Fig. 2]) and the patient was discharged.

Fig. 1 CT image of the perigastric abscess.

Fig. 2 CT after EUS-guided drainage using a double pigtail stent.

After confirming resolution of the abscess the stent was removed, pneumatic dilation was repeated, and the site of entry was sutured. An upper gastrointestinal series showed no leakage.

Two months later, the patient had a recurrent abscess. Pneumatic dilation was repeated, followed by EUS-guided drainage using a hot LAMS (1.5 cm) ([Fig. 3]). The abscess was lavaged. Two double pigtail stents were deployed inside a lumen apposing metal stent (LAMS). A nasoduodenal feeding tube was placed. The patient was discharged.

Fig. 3 CT after EUS-guided drainage using LAMS.

After confirming resolution of the abscess, the stents and the feeding tube were removed. A septum separated the cavity from the gastric lumen ([Fig. 4]). Septotomy [4] and pneumatic dilation were performed ([Fig. 5]). The patient was discharged.

Fig. 4 Septum separating the cavity from the gastric lumen.

Fig. 5 Endoscopic image after septotomy.

Endoscopy 3 months later showed epithelialization of the cavity ([Fig. 6]). The patient has been asymptomatic for the last 4.5 months.

Fig. 6 Endoscopic image showing collapse and epithelialization of the cavity.

In conclusion, EUS-guided drainage with a LAMS can be used to widen a refractory micro-fistula after sleeve gastrectomy to allow septotomy.

Video 1 Endoscopic management of a refractory leak after sleeve gastrectomy.

Competing interests

The authors declare that they have no conflict of interest.e

• References

• 1 Rosenthal RJ, Panel IS. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of > 12,000 cases. Surg Obes Rel Dis 2012; 8: 8-19
• 2 Vargas EJ, Dayyeh BK. Keep calm under pressure: a paradigm shift in managing postsurgical leaks. Gastrointest Endosc 2018; 87: 438-441
• 3 Kumbhari V, Dayyeh BK. Keeping the fistula open: paradigm shift in the management of leaks after bariatric surgery?. Endoscopy 2016; 48: 789-791
• 4 Diaz R, Welsh LK, Perez JE. et al. Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy: Meeting presentations: Digestive Disease Week 2019. Endoscopy international open 2020; 8: E70-E75

Publication History

Article published online:
19 February 2021