Endoscopy 2022; 54(01): E38-E39
DOI: 10.1055/a-1375-0159
E-Videos

Endoscopic septotomy for fistula after bariatric surgery

,
,
,
Rodrigo Silva de Paula Rocha
,
,
Thiago Ferreira de Souza
,
 

Gastric fistula following bariatric surgery is a complication with considerable morbidity and mortality [1] [2]. After Roux-en-Y gastric bypass (RYGB), the gastric pouch may develop a chronic fistula and the formation of a perigastric cavity bounded by a septum. The altered anatomy chronically elevates the intraluminal pressure, impairing emptying of the perigastric cavity and perpetuating the fistula [3].

Endoscopic septotomy is a minimally invasive technique for cutting the septum. The goals are ensuring adequate patency of the perigastric cavity, decreasing its pressure, and draining the fistula [1] [4] [5].

A 67-year-old woman underwent a RYGB (body mass index: 48 kg/m² before, 25 kg/m² after). She developed a gastrocutaneous fistula, which was unsuccessfully treated with a long-term nasoenteric tube. Eight months after RYGB, she was referred for endoscopic assessment ([Video 1]). Sutures were identified in the greater curvature of the gastric pouch. They were removed with endoscopic scissors and a perigastric cavity (bounded by a septum) with a fistula orifice in it was identified. The fistula orifice was initially treated with argon plasma coagulation and a guidewire was externalized through the fistula’s cutaneous orifice ([Fig. 1]), with placement of a 7-Fr double-pigtail stent in the fistula tract. After 3 months, the gastrocutaneous leak was reduced but not resolved. We removed the pigtail, performed a septotomy with an IT knife, and placed an esophageal fully covered (28 × 160 mm) self-expandable metal stent. The proximal end of the stent was fixed by endosuture to avoid migration. After 1 week, the stent was removed and the patient was able to take a soft diet. Four weeks later, the cutaneous fistula orifice was closed ([Fig. 2]) and esophagogastroduodenoscopy confirmed closure of the fistula’s gastric orifice ([Fig. 3]). At 3 weeks’ follow-up, the patient was asymptomatic and doing well on a regular diet.

Video 1 Complex fistulas after bariatric surgery require challenging endoscopic management. We report a case of bariatric surgery complicated by gastrocutaneous fistula, which was successfully treated with endoscopic septotomy.


Quality:
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Fig. 1 Guidewire externalized through the cutaneous orifice of the fistula.
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Fig. 2 The cutaneous fistula orifice is closed.
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Fig. 3 Endoscopic appearance of the perigastric cavity: a after suture removal, b after 7-Fr double-pigtail insertion through the fistula orifice, and c after treatment with argon plasma coagulation and 7-Fr double-pigtail stent. d Closed fistula after septotomy (final appearance).

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Mateus Bond Boghossian, MD
Av. Dr Enéas de Carvalho Aguiar 225, 6º andar, bloco 3
Cerqueira César
05403-010 – São Paulo, SP
Brazil    

Publication History

Publication Date:
19 February 2021 (online)

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Guidewire externalized through the cutaneous orifice of the fistula.
Zoom Image
Fig. 2 The cutaneous fistula orifice is closed.
Zoom Image
Fig. 3 Endoscopic appearance of the perigastric cavity: a after suture removal, b after 7-Fr double-pigtail insertion through the fistula orifice, and c after treatment with argon plasma coagulation and 7-Fr double-pigtail stent. d Closed fistula after septotomy (final appearance).