Endoscopic treatment of post vertical gastrectomy fistula: septotomy associated with air expansion of incisura angularis.

INTRODUCTION

Treatment of gastric leaks met new challenges with sleeve gastrectomy, as exclusive bariatric surgery[1]. Mistakenly seen as simpler, many inexperienced surgeons in laparoscopic and bariatric surgery began its use in patients. Was recognized that these fistulas are difficult to treat requiring multiple endoscopic treatments, reoperation and gastric resection[2,3,4]. Using the same principle of septotomies performed in gastric bypass complications, this pioneering author used this method for cases of fistula of the esophagogastric angle and gastric body after vertical gastrectomy.

CASE REPORT

Woman 54 year old with grade III obesity (BMI=43.2 kg/m2) associated with hypertension and severe arthropathy of the right knee underwent laparoscopic sleeve gastrectomy without complications and oversuture on staple line. Evolved with systemic signs of fistula (tachycardia, tachypnea, fever and foul smelling acid secretion in the drain) on the 9th day postoperatively. Was treated in the service of origin with antibiotics and nutrition via a nasogastric tube. Endoscopy observed fistulous orifice of 10 mm in the topography of the esophagogastric angle. Computed tomography showed perigastric cavity, but with no intra-abdominal abscesses. Contrasted radiography study demonstrated extravasation on angle site (Figure 1); clinically it was, on daily basis by Penrose drain number 2, of 30-50 ml. She was referred for endoscopic treatment on day 30 after surgery which revealed a fistulous hole 10-12 mm in esophagogastric angle and stenosis with excessive angulation of the incisura angularis (Figure 2).

Figure 1

Radiography showing contrast extravasation forming an lateral extra-gastric cavity at the site of the esophagogastric angle

Figure 2

Endoscopic septotomy procedure: A) endoscopic appearance of the fistula at the esophagogastric angle; B) septotomy being held

During the endoscopic procedure performed in the operating room with patient with respiratory intubation , the first step was to expand the incisure with Rigiflex type balloon 40 mm in high pressure. Later there was the opening of the mucous septum between peri-gastric pouch abscess cavity and the body lumen in itself (septotomy or septoplasty or “internal endoscopic drainage”). It was performed with argon catheter 2 l/m and 90 w, in order to avoid bleeding in this inflamed and hypervascularized area (Figure 3). The drain that communicated the peri-bag cavity skin was removed in the same procedure, due it was considered epithelized the fistula interior by time evolution. A liquid diet was started in 24 h.

Figure 3

Evolution of the healing process: A) initial appearance after septotomy with complete opening; B) final appearance in endoscopic control on day 30 post-septotomy

Endoscopic control was done after five days for completion of septoplasty with argon, observation of the incisura angularis and if the gastric pouch axis was already rectified. The fistula stopped draining to the skin on the 7th day after the start of endoscopic treatment. The pre-endoscopic cavity formed by the fistula had its full resolution at 30 days (Figure 3), although the patient already carry out her activities and feeding with no problems.

DISCUSSION

Currently the author has treated 10 such cases with complete resolution in all no later than 60 days after the start of endoscopic treatment.

The proposed combination - dilation and septotomy with argon - unlike other services of bariatric endoscopy over the country, allows earlier resolution of post-sleeve gastrectomy fistulas, thus reducing the length of hospital stay, the need for enteral nutritional support or prolonged parenteral nutrition, as well as the need for reoperation and the risk of unfavorable outcome. The author do not makes the opening of the fistula before the 30th postoperative day, because before this time there is the possibility of inexistence of healing blockage of the fistula area and the risk of penetration into free abdominal cavity with endoscopic devices. Generally with the more "forced" dilations mucosal laceration may occurs, but with only minor bleeding, not requiring hemostasis.