Vitor O Brunaldi1, Daniel Riccioppo, PhD, MD2, Diogo T de Moura, PhD, MD2, Flavio H Morita, MD1, Rodrigo S Rocha, MD1, Mauricio K Minata, MD1, Marco A Santo, PhD, MD2, Eduardo G de Moura, PhD, MD1. 1Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, 2Bariatric and Metabolic Surgery Unit, University of São Paulo Medical School
We report a case of a 55 years-old female patient who underwent a sleeve gastrectomy due to class III obesity. She had a past medical history of a kidney transplant due to end-stage chronic kidney disease. Seven days after surgery after the bariatric procedure, the drain output increased suddenly and after ingestion of methylene blue, we could identify bluish output, suggesting gastric fistula. The patient was clinically stable so we decided for conservative treatment. We promptly put the patient on broad-spectrum antibiotics and NPO and referred to Endoscopy unit for a stent placement. A large bariatric self-expandable metallic stent (28mmx24cm) was chosen and successfully deployed to completely occlude the orifice identified in the proximal corpus. We initiated liquid diet a day after SEMS placement but she experienced another increase in the drain output. Therefore, we kept her on NPO and endoscopically placed a nasoenteral feeding tube. She was discharged one week after SEMS placement and returned for clinical consultation three days later. She complained of the darkish and high volume drain output. She was readmitted for endoscopic assessment of the SEMS. During the procedure, we identified a large perforation in the distal esophagus, where the SEMS anchored. The patient was then conducted to emergency surgery. Intraoperatively, we could identify both esophageal perforation and gastric fistula. We were able to repair both defects and place mediastinum and peritoneal drains. Also, we performed a jejunostomy for feeding. Postoperatively, she was referred to ICU and was on vasoactive drugs for 4 days. Ten days after surgery, we performed an endoscopy to remove the SEMS, and we were able to identify the esophageal perforation and the mediastinum drain. Then, we initiated the endoscopic vacuum therapy for the perforation with drain exchange every 3-5 days. Fifty days later, the perforation was completely closed, and the gastric fistula became an ulcer with no contrast leakage. Currently, she is clinically stable, on oral liquid diet and enteral diet through jejunostomy. Hospital discharge is being planned.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88119
Program Number: V019
Presentation Session: Complications/Interesting Case Videos Session
Presentation Type: Video