Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract

Background and study aims: Diverse endoscopic methods, such as placement of temporary self-expandable stents, have proven effective for the treatment of post-bariatric surgery leaks. However, some patients do not respond to the usual endoscopic treatment. This study tested the efficacy of an alternative treatment strategy based on trans-fistulary drainage with double-pigtail plastic stents.

Patients and methods: We performed a retrospective analysis of patients with abdominal collections following bariatric surgery who were treated by trans-fistulary stenting between May 2007 and February 2015. Clinical success was defined as a sustained (> 4 months) clinical resolution (patient discharged from the hospital without antibiotics and able to resume a normal diet) and radiological response. Patient records, radiological images, and the hospital endoscopy database were reviewed.

Results: A total of 33 patients (26 women/7 men, mean age 42 years [SD 11.2]) were included. Collections occurred after sleeve gastrectomy (n = 28) or after gastric bypass (n = 5). Fourteen patients were treated by trans-fistulary stenting as primary treatment, and 19 patients had undergone previous unsuccessful endoscopic treatment. No serious complication occurred during the drainage procedure. Clinical success was achieved in 26 patients (78.8 %). In two successfully treated patients, stents are still in place. Spontaneous stent migration occurred in 12 patients. In 12 patients, the stents were removed, either electively (n = 5) or because of complications (ulcerations n = 3, upper gastrointestinal symptoms n = 3, splenic hematoma n = 1).

Conclusions: Trans-fistulary drainage of post-bariatric abdominal collections is safe and associated with high success rates. This technique can be considered in previously untreated patients, when a collection is not properly drained percutaneously, or after failure of other endoscopic treatments.

^* These authors contributed equally to this work.

• References

• 1 Yang L, Colditz GA. Prevalence of overweight and obesity in the United States, 2007 – 2012. JAMA Intern Med 2015; 175: 1412-1413
• 2 Ng M, Fleming T, Robinson M et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980 – 2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766-781
• 3 Puzziferri N, Roshek III TB, Mayou HG et al. Long-term follow-up after bariatric surgery: a systematic review. JAMA 2014; 312: 934-942
• 4 ASGE Standards of Practice Committee. Evans JA, Muthusamy VR et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 2015; 81: 1063-1072
• 5 Fernandez Jr AZ, DeMaria EJ, Tichansky DS et al. Experience with over 3000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc 2004; 18: 193-197
• 6 Podnos YD, Jimenez JC, Wilson SE et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003; 138: 957-961
• 7 Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012; 26: 1509-1515
• 8 Carrodeguas L, Szomstein S, Soto F et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 2005; 1: 467-474
• 9 Trastulli S, Desiderio J, Guarino S et al. Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials. Surg Obes Relat Dis 2013; 9: 816-829
• 10 Eisendrath P, Cremer M, Himpens J et al. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy 2007; 39: 625-630
• 11 Murino A, Arvanitakis M, Le Moine O et al. Effectiveness of endoscopic management using self-expandable metal stents in a large cohort of patients with post-bariatric leaks. Obes Surg 2015; 25: 1569-1576
• 12 El Mourad H, Himpens J, Verhofstadt J. Stent treatment for fistula after obesity surgery: results in 47 consecutive patients. Surg Endosc 2013; 27: 808-816
• 13 Swinnen J, Eisendrath P, Rigaux J et al. Self-expandable metal stents for the treatment of benign upper GI leaks and perforations. Gastrointest Endosc 2011; 73: 890-899
• 14 Voermans RP, Le Moine O, Von Renteln D et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol 2012; 10: 603-608
• 15 Gomez V, Lukens FJ, Woodward TA. Closure of an iatrogenic bariatric gastric fistula with an over-the-scope clip. Surg Obes Relat Dis 2013; 9: e31-33
• 16 Toussaint E, Eisendrath P, Kwan V et al. Endoscopic treatment of postoperative enterocutaneous fistulas after bariatric surgery with the use of a fistula plug: report of five cases. Endoscopy 2009; 41: 560-563
• 17 Evans JA, Branch MS, Pryor AD et al. Endoscopic closure of a gastrojejunal anastomotic leak (with video). Gastrointest Endosc 2007; 66: 1225-1226
• 18 Papavramidis ST, Eleftheriadis EE, Papavramidis TS et al. Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant. Gastrointest Endosc 2004; 59: 296-300
• 19 Fischer A, Thomusch O, Benz S et al. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg 2006; 81: 467-472
• 20 El Hajj I, Imperiale T, Rex D et al. Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes. Gastrointest Endosc 2014; 79: 589-598
• 21 Freeman RK, Ascioti AJ, Giannini T et al. Analysis of unsuccessful esophageal stent placements for esophageal perforation, fistula, or anastomotic leak. Ann Thorac Surg 2012; 94: 959-965
• 22 Pequignot A, Fuks D, Verhaeghe P et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?. Obes Surg 2012; 22: 712-720
• 23 Donatelli G, Dumont JL, Cereatti F et al. Treatment of leaks following sleeve gastrectomy by endoscopic internal drainage (EID). Obes Surg 2015; 25: 1293-1301
• 24 Gupta T, Lemmers A, Tan D et al. EUS-guided transmural drainage of postoperative collections. Gastrointest Endosc 2012; 76: 1259-1265
• 25 Rosenthal RJ, Diaz AA et al. International Sleeve Gastrectomy Expert Panel. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of > 12,000 cases. Surg Obes Relat Dis 2012; 8: 8-19
• 26 Leenders BJ, Stronkhorst A, Smulders FJ et al. Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital. Surg Endosc 2013; 27: 2751-2759
• 27 Mercky P, Gonzalez JM, Aimore Bonin E et al. Usefulness of over-the-scope clipping system for closing digestive fistulas. Dig Endosc 2015; 27: 18-24
• 28 Donatelli G, Catheline JM, Dumont JL et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. Obes Surg 2015; 25: 1258-1260
• 29 Baretta G, Campos J, Correia S et al. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc 2015; 29: 1714-1720
• 30 Eisendrath P, Devière J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol 2015; 12: 701-710