Endoscopic septotomy for fistula after bariatric surgery

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.

Fig. 1 Guidewire externalized through the cutaneous orifice of the fistula.

Fig. 2 The cutaneous fistula orifice is closed.

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).

Endoscopy_UCTN_Code_CPL_1AH_2AG

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Baretta G, Campos J, Correia S. et al. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc 2015; 29: 1714-1720
• 2 Campos JM, Pereira EF, Evangelista LF. et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011; 21: 1520-1529
• 3 Angrisani L, Hasani A, Santonicola A. et al. Endoscopic septotomy for the treatment of sleeve gastrectomy fistula: timing and indications. Obes Surg 2018; 3: 846-847
• 4 Rodrigues-Pinto E, Repici A, Donatelli G. et al. International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks. Endosc Int Open 2019; 7: E1671-E1682
• 5 Mahadev S, Kumbhari V, Campos JM. et al. Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections. Endoscopy 2017; 49: 504-508

Publikationsverlauf

Artikel online veröffentlicht:
19. Februar 2021