Kevin Brown, MD, Alisan Fathalizadeh, MD, John Rodriguez, MD. Cleveland Clinic Foundation
Objective: Gastric leaks following bariatric surgery are among the most feared postoperative complications. Although revisional surgery is a treatment option, it carries a higher morbidity and mortality than conservative measures and endoscopic therapy. Although only a handful of cases exist for endoluminal vac therapy (EVT) for the treatment of these leaks, we hope to present a novel technique for vac placement to achieve similar results with a more pleasant course for the patient.
Case: A 45-year-old female presented to our institution after developing a chronic leak after sleeve gastrectomy complicated by an abscess cavity involving the spleen, distal pancreas and left crus of the diaphragm. At her index operation, she underwent a laparoscopic lysis of adhesions converted to open revision to roux-en-Y gastric bypass with splenectomy and distal pancreatectomy. She developed a gastric leak along the gastric pouch staple line. This was initially managed by endoluminal stent placement and OVESCO clip placement. Subsequently, an internal pigtail drain was attempted. A 20 french percutaneous endoscopic jejunostomy (PEJ) tube was placed for enteral access.
Technique: The patient tolerated feeds, however, imaging demonstrated a continuous abscess cavity. A repeat EGD was performed. Via a guidewire exchange, the 20 french PEJ tube was removed and replaced by a 12 french MIC balloon jejunostomy tube. The wire was again inserted adjacent to the MIC tube under direct visualization and fed in a retrograde manner. A 12 french nasogastric tube was inserted over the wire through the same jejunostomy site and under direct vision grasped with rat-toothed forceps endoscopically. This end of the tube was pulled through the mouth. A black sponge trimmed to size was secured to the end of the NG tube with a 2-0 nylon suture. The tube was pulled antegrade to the abscess cavity. Using the forceps, the sponge was placed in position endoscopically and -150mmHg suction was applied to the tube.
Preliminary results: As this is a single case, we have followed the patient with a timeline of returning to the OR every 3-4 days to exchange the vac sponge and assess the cavity. With subsequent visits, the cavity continued to demonstrate increasing granulation tissue and decrease in total volume. The patient’s nutritional status has improved due to full enteral nutrition augmented with oral intake.
Conclusions: Increased investigation into the efficacy of endoluminal vac therapy for leaks post bariatric procedures is warranted. We however have demonstrated a novel approach to the placement of an endoluminal vac using endoscopic assistance sharing the same jejunocutaneous tract as a feeding jejunostomy tube. This approach provides enteral nutrition, a single fistula tract, and avoids a nasoenteric tube which not only eliminates complications associated with nasoenteric tubes but provides increased patient comfort during an extended hospital stay.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 98888
Program Number: ETP738
Presentation Session: Emerging Technology Poster Session (Non CME)
Presentation Type: Poster