Long-term endoscopic follow-up after closure of a post-bariatric surgery fistula with a cardiac septal defect occluder

Bariatric surgery is currently the most effective treatment strategy for obesity; however, post-surgical fistulas may occur in up to 8.3 % of patients following traditional Roux-en-Y gastric bypass (RYGB) [1]. Currently endoscopic treatment of these complications remains challenging, with unsuccessful fistula closure occurring in 20 % of patients [1] [2]. More recently, the use of a cardiac septal defect occluder (CSDO) device has been proposed as a novel treatment for the closure of gastrointestinal fistulas. A CSDO is a double-disc self-expanding closure device made of nitinol and interwoven polyester. The successful use of CSDOs in the management of gastrointestinal surgical and bariatric leaks has been reported; however, there are limited data regarding long-term outcomes [3] [4]. In this video, we describe the successful closure of a gastrocutaneous fistula using a CSDO and demonstrate persistent closure at long-term follow-up ([Video 1]).

Video 1 Long-term follow-up of successful gastrocutaneous fistula closure using a cardiac septal defect occluder.

A 36-year-old man with a history of RYGB 3 years previously presented to our institution with a gastrocutaneous fistula. Initial treatment with a fully covered self-expandable metal stent (SEMS) was unsuccessful, and the patient subsequently underwent treatment with a CSDO [5]. The CSDO procedure was immediately successful with closure of the gastrocutaneous fistula and, at 1-year follow-up, endoscopy demonstrated an intact, well-positioned CSDO, with no evidence of a fistula ([Fig. 1 a]). At 3-year follow-up, routine endoscopy did not identify the CSDO ([Fig. 1 b]). An upper gastrointestinal contrast study was performed and confirmed that the CSDO was not present in the gastrointestinal lumen or intra-abdominal cavity ([Fig. 2]). Despite the presumed migration of the device, the fistula remained closed with no recurrent fistula or leakage noted.

Fig. 1 Endoscopic images showing: a the well-positioned cardiac septal defect occluder, with closure of the gastrocutaneous fistula at 1-year follow-up; b no evidence of leakage or a fistulous tract, despite apparent migration of the cardiac septal defect occluder, at 3-year follow-up.

Fig. 2 Image from an upper gastrointestinal series showing no evidence of gastrointestinal leakage or a fistula, and no evidence of the previously placed cardiac septal defect occluder.

In summary, the use of a CSDO device appears to be a safe and effective long-term treatment for patients with post-surgical gastrocutaneous fistulas. While more data are needed to verify these results, CSDOs may be a feasible alternative for gastrointestinal leaks and fistulas that are refractory to traditional endoscopic techniques.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Okazaki O, Bernardo WM, Brunaldi VO. et al. Efficacy and safety of stents in the treatment of fistula after bariatric surgery: a systematic review and meta-analysis. Obes Surg 2018; 28: 1788-1796
• 2 de Moura DTH, Sachdev AH, Thompson CC. Endoscopic full-thickness defects and closure techniques. Curr Treat Options Gastroenterol 2018; 16: 386-405
• 3 Baptista A, de Moura DTH, Jirapinyo P. et al. Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas. Gastrointest Endosc 2019; 89: 671-679.e1
• 4 De Moura DTH, Baptista A, Jirapinyo P. et al. Role of cardiac septal occluders in the treatment of gastrointestinal fistulas: a systematic review. Clin Endosc 2020; 53: 37-48
• 5 de Moura DTH, Ribeiro IB, Funari MP. et al. Novel use of a cardiac septal occluder to treat a chronic recalcitrant bariatric fistula after Roux-en-Y gastric bypass. Endoscopy 2019; 51: E111-E112

Publication History

Article published online:
16 April 2021