Bariatric Postoperative Fistula: A Life-saving Endoscopic Procedure

Giorgio Baretta, PhD, Joao Henrique Lima, PhD, Josemberg Campos, PhD, Manoel Galvao Neto, MSc. Vita Batel Hospital – Department of Bariatric Advanced Endoscopy.

Background: Fistula after batiatric surgery occurs in 0,8% to 7% with high incidence of mortality, reoperations and long hospital stay. Some reasons are well-described such as distal obstruction: stenosis of the anastomosis, restrictive ring and narrowing on angularis incisura like a “time machine”. Others like stappling of the distal esophagus, His angle ischaemia, tension on the anastomosis, superobesity and comorbidities are also important. A great number of endoscopic procedures have been used to close the fistula, such as biological glue (tissucol), stents, surgisis and endoclips. The authors describe the feasibility of this new technique called septotomy or endoscopic internal drainage that avoids reoperations and allows an earlier hospital discharge with no mortality.

Methods: Twenty-eight patients underwent to an endoscopic internal drainage – septotomy – after bariatric surgery. All procedures were done in the operating room with general anesthesia and antibiotics. The cut of the septum was made with a needle knife or argon plasma in order to comunicate the perigastric cavity with the pouch. This technique allows the drainage of the perigastric abscess into the pouch due to its lower pressure after the cut. If any distal obstuction had been present, a dilatation with a pneumatic balloon was performed. Water per oral was initiated 24 hours later.

Results: Twenty-eight patients were included to septotomy with no mortality. Fourteen of them (50%) were submitted to gastric bypass, nine patients (32,1%) to sleeve gastrectomy, four patients (14,3%) to duodenal switch and one patient (3,6%) to a conversion of gastric bypass in duodenal switch. All of them presented with His angle fistula. Eight patients with gastric bypass (57,1%) had stenosis of the anastomosis treated with balloon dilatation. All sleeve gastrectomy and duodenal switch patients (100%) presented with angularis incisura stenosis treated with a rigiflex balloon as well as the patient submitted to the conversion for duodenal switch. The number of endoscopic sessions to perform the cut of septum range from 1 (14 patients) to 6 (1 patient), with 4 sessions made in 1 patient, 3 sessions made in 2 patients, 2 sessions made in 10 patients. Nine patients were submitted to this procedure as a day procedure. Only 1 patient need an endoscopic prosthesis due to an abdominal sepsis after the internal drainage. This patient was discharge 30 days after the procedure. The time for the first endoscopic procedure was on the 7th PO day and the lastest 5 years after the surgery in a patient with a late onset of fistula after duodenal switch.

Conclusions: This new endoscopic procedure is safe, feasible and effective. It avoids reoperations and allows oral feeding and early hospital discharge with no mortality.

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