Bariatric postoperative fistula: a life-saving endoscopic procedure

Abstract

Gastric fistula after bariatric surgery has high morbi-mortality, and treatment is a challenge due to persistent abscess and/or distal stenosis. The present study evaluated the efficacy and safety of stricturotomy/internal drainage, a novel endoscopic procedure that can avoid re-operation and allow early oral feeding. This prospective, non-randomized study, with no control or sham group, included 27 patients (74.07 % were female), approved by the local IRB, who underwent the following bariatric surgeries: Roux-en-Y gastric bypass (RYGB; n = 14, 51.85 %), laparoscopic sleeve gastrectomy (LSG; n = 9, 33.33 %) and duodenal switch (DS; n = 4, 14.81 %). The patients presented with gastric fistulas which were treated by internal drainage/stricturotomy. The mean patient age was 42.67 years, and the mean pre-operative BMI was 40.69 kg/m². Balloon dilation was performed if distal stenosis and/or axis deviation was present. The first endoscopic procedure was applied on the 15th day after RYGB and the 30th day after LSG and DS. All patients presented with His angle fistula. Eight patients (57.1 %) had stenosis of the anastomosis after RYGB and were treated with balloon dilatation (20 mm). The patients submitted to LSG and DS had stenosis at the angularis incisure and were treated with achalasia balloon dilation (30 mm). The number of endoscopic sessions for stricturotomy ranged from 1 to 6. Two patients experienced bleeding after dilation, and one had perforation. The mean time to achieve fistula closure was 18.11 days (range, 1–72 days) without mortality. All the fistulas closed. This novel endoscopic procedure is safe, feasible, and effective, avoiding re-operation, allowing early oral feeding and discharge.