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Refractory complex gastro-broncho-cutaneous fistula after laparoscopic sleeve gastrectomy: a novel technique for endoscopic management. Emad Abdallah MD, Hosam Hamed MD, Mohamed Fikry Ms
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S1550-7289(16)00071-X http://dx.doi.org/10.1016/j.soard.2016.02.026 SOARD2589
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Surgery for Obesity and Related Diseases
Cite this article as: Emad Abdallah MD, Hosam Hamed MD, Mohamed Fikry Ms, Refractory complex gastro-broncho-cutaneous fistula after laparoscopic sleeve gastrectomy: a novel technique for endoscopic management., Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2016.02.026 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Refractory complex gastro-broncho-cutaneous fistula after laparoscopic sleeve gastrectomy: a novel technique for endoscopic management. Authors: 1. Emad Abdallah (MD). Surgical Department, Mansoura University, Mansoura, Egypt 2. Hosam Hamed (MD). Gastrointestinal Surgical Center, Surgical Department, Mansoura University, Mansoura, Egypt. 3. Mohamed Fikry (Ms). Surgical Department, Mansoura University, Mansoura, Egypt. Short title: Treatment of post-sleeve gastrectomy fistula. Corresponding author: Hosam Hamed Contact information: Address: Mansoura Gastrointestinal Surgical Center, Jehan street, Mansoura, Dkahleya, Egypt. Mobile number: 00201006178599 Email:
[email protected] Postal code: 35516 Fax number: 0020502243220 Keywords: Sleeve gastrectomy; refractory fistula; chronic fistula; endoscopic stenting; SengstakenBlakemore tube Introduction: Laparoscopic sleeve gastrectomy (LSG) is a widely used effective stand-alone procedure for treatment of morbid obesity[1]. However, it is not a procedure without complications[2,3]. Staple line leakage is the most serious complication after primary LSG with an incidence of 1.4-4%[4-6]. In rare cases, chronic proximal gastric leakage transforms into gastrobronchial fistula (GBF)[7]. Factors associated with the occurrence and persistence of gastric fistula include distal stenosis, twisted gastric tube, intra-gastric
hypertension, stapling and ischemia at lower esophagus, multiple co-morbidities and super obesity[8]. Variable techniques had been described for treatment of gastric fistulae after LSG. Endoscopic approach is the primary line of treatment of gastric fistula after LSG[9]. Endoscopic procedures include application of self-expanding metallic stent, balloon dilatation of distal stricture and stricturotomy[8]. Re-operation for treatment of gastric fistula after LSG is associated with higher morbidity and mortality and it is indicated in chronic and refractory fistulae[10]. Surgical procedures include surgical drainage, total gastrectomy and roux-en-Y esophagojejunostomy, Roux-en-Y gastrojejunostomy and fistulo-jejunostomy
[6,11]
. Hybrid endoscopic and surgical technique is reported by many
authors. In this article, we report a novel endoscopic technique that was successful in management of a chronic GBF explaining its merits and benefits. Case Presentation and management: The case is a 34-year-old male who underwent LSG in another facility when his BMI was 44 kg/m2 without co-morbidities. Early leakage was diagnosed on the third postoperative day and managed by laparoscopic drainage and endoscopic insertion of self-expanding fully covered stent. Two days later, intraperitoneal hemorrhage and hemothorax occurred and it was managed by cessation of anticoagulant, insertion of intercostal tube (ICT) and laparotomy which revealed no definite source of bleeding. Then, the ICT was obstructed and the case was managed by thoracotomy, evacuation of hematoma and insertion of two ICTs. One month later, esophageal stent was removed. After removal of the stent, gastro-broncho-cutaneous fistula (GBCF) became evident
(Figures: 1) through the scar of thoracotomy and abdominal computerized tomography (CT) revealed bilateral subphrenic collection. This was managed by ultrasound guided tube drainage of left and right subphrenic collections and endoscopic insertion of esophageal stent (15 cm) which failed to stop leakage. Then, the patient was referred to us 1.5 month after the primary surgery.
On examination, the patient showed signs of toxemia in the form of tachycardia (110-120 beat per minute), dyspnea, generalized weakness and fatigability. The thoracotomy scar was discharging pus through multiple orifices. Contrast study revealed a gastro-broncho-cutaneous fistula (GBCF) connected to the gastroesophageal junction. Upper endoscopy revealed the wide internal opening of the GBCF with the upper part of the stent twisted inside its opening. The migrated stent was removed and a fully covered self-expanding stent (Taewoong Niti-STM Megastent, Taewoong medical, Korea) was inserted. The fistulous output decreased and oral intake was started 24 hours after stent insertion. One week later, fistulous output increased dramatically and endoscopy revealed migrated stent downwards and repositioning was done. Three days later, remigration occurred. Parentral nutrition was not possible due to difficult access to peripheral and central veins by the hands of 2 expert ICU anesthesiologists.
The condition was managed by endoscopic repositioning of the stent with insertion of a Sengstaken-Blakemore (SB) tube (18 French) through the stent till its tip was placed in the duodenum, the gastric balloon was below the stent and the esophageal balloon was inside the stent. The tube was inserted through nose and then pulled from
mouth then its tail was grasped by rat tooth foreceps (Endo-flex, Germany) coming out of the channel of the gastroscope. The tube tip was navigated through the stent downwards till the second part of the duodenum. Then Savary guidewire (Wilson-Cook Medical Inc., Winston Salem, NC, USA) was introduced through feeding channel till seen from holes at the end of the tube. The idea from using this guidewire was to allow withdrawal of the scope and grasper without pulling the tube out again (Figure: 2).
The gastric and esophageal balloons were inflated by saline up to 20 mmHg under direct endoscopic vision. Enteral feeding through the tube was started few hours later. In the next days, oral contrast study revealed persistent leakage. This was managed by deflating the balloons, gradual pull-up of the tube and re-inflation using saline again till leakage stopped under fluoroscopic guidance (Figure: 3). Once the balloon was wellplaced and no further leakage was evident on fluoroscopy, both balloons were inflated more to a pressure of 25 mmHg. Two cutaneous fistulae stopped discharge completely 2 days after optimum repositioning. Gradual inflation of the esophageal balloon by saline was done every three days up to 50 mmHg while the gastric balloon is kept inflated up to 25 mmHg by saline.
SB tube was blocked and removed after 18 days. Contract study revealed absence of leakage (Figure: 4). The stent was removed one month later followed by endoscopic dilatation for a stricture at the incisures using achalasia balloon (3.5cm) (AchalasieBallon, Endo-flex, Germany). Endoscopic dilatation of the stricture was repeated every 2 weeks using achalasia balloon (4 cm) for three times. The patient regained health and
toxemic manifestations subsided. Serial follow-up contrast studies revealed fistulous closure.
Discussion:
Gastro-broncho-cutaneous fistula (GBCF) is a devastating serious complication after different bariatric procedures[12,13]. Its actual incidence is not accurately known. It is associated with high morbidity and mortality rate[14]. Being a chronic fistula, its treatment is challenging and major re-operation is usually necessary[15]. In this report, we present our experience with a novel technique for management or chronic refractory GBCF by endoscopic placement of fully covered self-expandable stent (Endo-flex, Germany) and SB tube.
Endoscopic insertion of SB tube is demanding and requires adequate experience in endoscopic techniques. The use of rat tooth forceps allowed firm grasping of SB tube without slipping. Its hard shaft allowed easy direction of the tube as malleability would lead to difficult progress through the alimentary lumen. Insertion of Savary guidewire helped easy withdrawal of the scope and foreceps without slippage out of the tube after its placement.
The use of SB tube carried many advantages. It prevented stent migration which is one of the most frequent complications after stent placement. Migration was prevented by the gastric balloon which is present in the antrum below the stent and the esophageal
balloon inside the stent. Another advantage of the SB tube was that inflation of the esophageal balloon lead to coaptation of the stent with the esophageal wall with complete plugging of the internal fistulous opening. This prevented leakage of fluids and saliva in the space between the stent and the esophageal wall which would lead to persistent fistula.
Gradual inflation of the esophageal balloon over more than 2 weeks lead to gradual dilatation of the gastric stricture which is a main contributing factor to persistent fistula. Esophageal balloon was not inflated beyond a pressure of 50 mmHg to avoid affecting the blood supply of the lower esophagus. We used saline instead of air to avoid leakage of air which would lead to less pressure exertion on the stent preventing full coaptation with the esophageal wall. There was no suction port in the tube proximal to the esophageal balloon so the patient had to spit saliva regularly. We think that using 4 lumen tube with one tube for suction of the secretions above the esophageal balloon might be better but it was not available in our institute at the time of management.
One of the main concerns during management of staple line leakage after LSG is adequate feeding. In the reported case, there was a true dilemma regarding patient feeding. Creation of surgical feeding jejunostomy was hazardous because of previous surgical explorations and the associated adhesions and increased likelihood of complications. Access to peripheral and central veins to allow parenteral nutrition was not possible by the hands of two expert anesthesiologists. SB tube allowed enteral feeding by conveying nutrients through the tube beside its role in controlling the fistulous
track. Its advantage over nasogastric tube feeding is that it prevented reflux of the nutrients by the inflated gastric balloon.
In conclusion, endoscopic stenting with SB tube placement was a safe and successful technique for management of this case of refractory leakage after LSG complicated by GBCF. Further studies on a larger sample are required to explore the validity and drawbacks of this technique in comparison to other treatment strategies.
No conflict of interest to be disclosed.
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Figure legends: Figure 1: Oral contrast study showing the gastro-broncho-cutaneous fistula. Figure 2: Highlights in the technique of endoscopic insertion of Sengstaken-Blakemore (SB) tube after repositioning of the migrated stent. (A) Migrated stent. (B) Stent repositioning by rat tooth forceps. (C) Holding the tip of SB tube after its retrieval from the mouth after nasal insertion to propagate it in the alimentary tract. (D) Securing the tip of SB tube in the duodenum. (E) Inflation of gastric balloon of SB tube in the antrum distal to the stent. (F) Inflation of the esophageal balloon of SB tube within the stent. Figure 3: Oral contrast study after placement of Sangestaken-Blakemore (SB) tube within the full-covered self expanding stent. (A) Before pulling up of the SB tube to seal the leakage under fluoroscopic guidance. (B) After proper positioning and inflation of esophageal balloon. (C) After removal of SB tube. Figure 4: Oral contrast study showing complete healing of the gastro-broncho-cutaneous fistula with free flow of the contrast distally to the duodenum with no distal stricture.
