Angled Glidewires and Angiographic Catheters in the Management of a Chronic Gastrocutaneous Fistula Resulting from a Sleeve Gastrectomy Staple Line Leak: A Case Report.

Mazen Al-Mansour, MD, Katelyn Levene, MD, Sabrena F Noria, MD, PhD. Division of General and Gastrointestinal Surgery, Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, 558 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.

Introduction: Management of a chronic gastrocutaneous fistula (GCF) secondary to sleeve gastrectomy (SG) staple line leaks include an arsenal of non-surgical and surgical approaches. Focusing on non-surgical methods, a common approach is controlling contamination via external drainage and exclusion of the gastric opening using covered esophageal stents. Less commonly, endoscopic injection of fibrin sealants into the tract either intraluminally or percutaneously is also employed. While these methods have been successful for short/straight tracts, they are less effective when tracts are longer and/or more tortuous. We present the use of angled glidewires and angiographic catheters to delineate and, with the application of fibrin glue, obliterate a chronic, tortuous GCF secondary to a sleeve leak.

Case Description: A 51 year-old female underwent a SG in August 2015, which was complicated by a proximal staple line leak resulting in a GCF. The fistula persisted for 12 months despite bowel rest, jejunostomy tube feeds, two attempts at endoscopic placement of covered esophageal stents, placement of a T-tube in the fistula tract, and injection of fibrin sealant into the gastric and cutaneous openings. Her care was transferred in July 2016, and due to her inability to tolerate the stent and persistent fistula output, a fistulogram was obtained. Imaging demonstrated a large peri-gastric cavity that communicated with the gastric sleeve and skin, and a previously placed esophageal stent (Figure 1). Given the tortuous nature of the tract, and inability to access it endoscopically, we opted to use to use a 0.89 mm flexible angled glidewire to access the tract and the large peri-gastric cavity from the cutaneous opening (Figure 2). A 6 Fr catheter was introduced over the wire and the anatomy of the tract/cavity was delineated with contrast agent (figure 3). Twenty milliliters of fibrin sealant was injected into the tract and the stent was removed. Fibrin was identified endoscopically within the lumen of the sleeve at the level of the leak, confirming tract filling (Figure 4). Follow-up upper GI swallow demonstrated a significantly smaller cavity and a narrower tract, with < 10cc output from the cutaneous opening. The patient remained on tube feeds and at her 2 week clinic visit demonstrated cessation of output at the level of the skin indicating healing.

Conclusion: Angled glidewires, angiographic catheters, and application of fibrin glue from the external skin opening are useful tools/approaches for delineation and obliteration of tortuous GCFs secondary to leaks after a SG.