Roux-En-Y Fistulo-Jejunostomy As a Salvage Procedure In Patients With Post-Sleeve Gastrectomy Fistula Mid term results

Elie K Chouillard, MD, PhD1, Salman Al Sabah, MD2, Antoine Younan, MD3, Georges Khoury, MD4, Rene Louis Vitte, MD1. 1PARIS POISSY MEDICAL CENTER, 2AMIRI HOSPITAL, KUWAIT CITY, 3BELLEVUE MEDICAL CENTER, BEIRUT, 4RIZK HOSPITAL, BEIRUT

Background: Sleeve Gastrectomy is currently the most common bariatric procedure in France. It achieves both adequate excess weight loss and significant reduction of comorbidities. However, leak is still the most common complication after sleeve gastrectomy. Its risk of occurrence is, albeit, < 3 % in specialized centers. Its management is difficult, long, and challenging. Although commonly endoscopic and nonoperative, the management of post sleeve fistulas could sometimes be surgical including peritoneal lavage, absces drainage, suturing of disrupted staple line, resleeve, gastric bypass, or total gastrectomy. Roux-en-Y fistulojejunostomy (RYFJ) has been described as a salvage option, with only scarce case reports published. We have already reported the early results of RYFJ for post sleeve gastrectomy fistula. In this study, we analyzed the mid-term results of the procedure emphasizing endoscopic, radiologic, and metabolic outcome.

Methods: Between January 2007 and December 2013, we treated 75 patients with post sleeve gastrectomy fistula. Prior to surgery, collections were either ruled out or treated by computerized tomography (CT) scan guided drainage or even surgery. Endoscopic stenting was then attempted. After optimisation of the nutritional status et in case of failure of endoscopic measures, some of the patients had RYFJ. The procedure was found to be safe and feasible with no mortality and 100 % leak control.

Mid-term results were assessed using clinical evaluation, metabolic biological analysis, upper digestive tract endoscopy (with pH metry and manometry), CT scan with upper series, and gastric scintigraphy.

Results: Between January 2007 and December 2013, 30 patients (22 women and 8 men) had RYFJ for post SG fistula. Mean age was 47 years (range, 22-59). Procedures were performed laparoscopically in all but 3 cases. Three patients were lost to follow-up. Mean follow up period was 22 months (18-90).

Mean BMI was 27.4 kg/m² (22-41). All anastomoses were patent. A detailed panel of the endoscopic findings is discussed. No significant abnormality was found on manometry. Emptying scintigraphy showed various panels with dual upper digestive pathway. Morphological, CT assessment of the stomach and the bowel loop was performed.

Conclusion: RYFJ is a safe and feasible salvage procedure for patients with post sleeve gastrectomy fistula. Mid-term outcome analysis confirms that fistula control is durable. Weight loss panel is satisfactory. No significant metabolic disturbances were found.

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