Laporoscopic Treament of Gastro-colic Fistula: A Rare Complication of Sleeve Gastrectomy

Fabio Garofalo, MD, Anne-Sophie Studer, MD, Henri Atlas, MD, Ronald Denis, MD, Pierre Garneau, MD, Radu Pescarus. Hopital du Sacre-Coeur de Montreal

Introduction: Chronic gastric leak after sleeve gastrectomy is one the most insidious complications in bariatric surgery. Multimodal treatment using endoscopic, surgical and interventional radiology approaches is often necessary. A gastric leak progresses rarely into a gastro-colic fistula and usually occurs when initial control of the leak is not achieved. The aim of this video is to show a minimally invasive laparoscopic treatment for a chronic fistula between the gastric antrum and transverse colon.

Methods and Procedures: A 43-year-old female, with no significant medical issues, was referred to our bariatric surgery department for treatment of gastro-colic fistula after sleeve gastrectomy. She had laparoscopic sleeve gastrectomy 4 years before in another country.  Ten days after the initial surgery she underwent a laparotomy and drainage of perigastric abscess. She was readmitted 8 days later for recurrent intra-abdominal abscess, treated by percutaneous drainage before being lost to follow-up. Eventually, she developed severe diarrhea (10-15 bowel movements per day) worsened by eating. Initial investigations included an EGD, colonoscopy, barium study, CT abdomen and pelvis and nutritional work-up. A non-malignant gastro-colic fistula was diagnosed between the gastric antrum and transverse colon.

Results: The endoscopic evaluation revealed a 8 mm fistula located in the proximal antrum. Endoscopic treatment of the fistula was attempted with an OTSC (Over-The-Scope-Clip) but failed because of the fibrotic nature of the fistula. After nutritional optimization the patient underwent a laparoscopic resection of the gastro-colic fistula with omental interposition and per-operative endoscopy. Separate closure within healthy tissue was obtained with a linear stapler on the colonic side and with laparoscopic suturing on the gastric side. The patient recovered well after the surgery and was discharged home after 4 days. At 3 months follow-up, the patient had normal bowel movements and a 3 kg weight regain.

Conclusion: Gastro-colic fistula is a rare complication after sleeve gastrectomy.  Endoscopic treatment of a chronic fistula is often difficult to achieve. Laparoscopic fistula resection with intraoperative endoscopy appears to be a safe and effective treatment.

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