Surgical management of chronic fistula after sleeve gastrectomy

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1 Surgery for Obesity and Related Diseases 9 (2013) Original article Surgical management of chronic fistula after sleeve A. Marius Nedelcu, M.D. *, Mehdi Skalli, M.D., Eric Deneve, M.D., Jean Michel Fabre, David Nocca Department of Surgery, Saint Eloi Hospital, CHRU Montpellier, 80 Av. Augustin Fliche 34295, Montpellier, Cedex 5, France Received December 12, 2012; accepted February 26, 2013 Abstract Keywords: Background: There is no clear definition of the chronic leak after sleeve. There are several endoscopic approaches, including endoprothese, endoscopic clips, endoscopic sealing glue, or balloon dilation. In case of failure of the endoscopic treatment, a definitive surgical approach can be attempted. The objective was to evaluate the surgical treatment of chronic leak after sleeve. Methods: From November 2010 through March 2012, 8 patients with chronic gastric fistula after laparoscopic sleeve had definitive surgical repair. The initial intervention, the diagnosis and management of the fistula, and the endoscopic approach were carefully reviewed. Results: Five patients had their original laparoscopic sleeve gastrectomies performed at another hospital, while 3 had laparoscopic sleeve at our institution. The mean period of time from the diagnosis of the fistula to definitive surgical treatment was 14.4 months (range 5 44 months). Seven patients initially had surgical drainage by (5) and by laparotomy (2), with concomitant feeding jejunostomy in 6 patients. The endoscopic treatment consisted of endoprothese in 4 patients, endoscopic sealing glue in 2 patients, and sequential approach with glue and prosthesis in 2 other patients. One patient was treated exclusively by endoscopic approach with no surgical drainage. The surgical procedures performed for chronic fistula were gastrojejunal lateral anastomosis (4), Roux-en-Y gastric bypass (2), and with esojejunal anastomosis (2). Four patients presented with postoperative fistula, with a mean healing time of 32 days (range days). No mortality was recorded. Conclusion: In chronic forms of fistulas with no improvements by endoscopic approach, the surgical treatment can be a solution. It remains a difficult procedure with a high percentage of leakage, but this type of fistula is more easily tolerated by the patient and heals faster. (Surg Obes Relat Dis 2013;9: ) Crown Copyright r 2013 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery. All rights reserved. Surgical management; Leak; Sleeve The increasing prevalence of morbid obesity and the fact that surgery is the only proven long-term effective treatment for this condition have led to the search for surgical techniques that can provide adequate weight loss with the least possible morbidity and mortality. * Correspondence: Adrian Marius Nedelcu, M.D., Department of Surgery, Saint Eloi Hospital, CHRU Montpellier, 80 Av. Augustin Fliche 34295, Montpellier, Cedex 5, France. nedelcu.marius@gmail.com Laparoscopic sleeve (LSG), a relative new procedure for bariatric surgery, was initially developed by Gagner et al. and constituted the first stage of bariatric surgery for the super-obese or high-risk patient. LSG is increasingly recognized as a valid stand-alone procedure for the surgical management of morbid obesity [1]. The mechanism of weight loss can be explained by gastric restriction, neurohormonal changes related to the gastric resection, or some other unidentified factors and is achieving /13/$ see front matter Crown Copyright r 2013 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery. All rights reserved.

2 880 A. M. Nedelcu et al. / Surgery for Obesity and Related Diseases 9 (2013) % 70% excess weight loss by 3 years [1]. A dreaded complication after sleeve is staple line leak. The reported gastric leak rates from the sleeve staple line are 1.4% 2.5% for primary sleeve gastrectomies and 16% 20% for reoperative surgery for which a previous gastric operation has been performed [2 5]. Numerous articles have been written about the different approaches for the gastric fistula, but few exist concerning the reconstructive surgical treatment of chronic gastric leak [6 10]. The purpose of the present study was to report our experience with this approach in 8 patients. To our knowledge, in the literature, this is the largest series reported for chronic gastric fistula (GF) treated by aggressive reconstructive surgery. Methods Eight patients (7 women and 1 man; mean age years) with an average body mass index (BMI) of 46.2 kg/m 2 who underwent LSG complicated by persistent high-output GF were enrolled in the study. Five patients had their original LSG surgery performed at another hospital and were referred to us with persistent gastric leaks, despite intensive measures, such as antibiotherapy, nutritional support, and treatment of the abdominal sepsis by reintervention, endoscopy, or computed tomography guided drainage, at the original institution. To this group, we added 3 patients who had their initial surgery performed in our institution. The demographic data, the initial intervention, the diagnosis time, and the initial management of the fistula are summarized in Table 1. The technique of LSG for the 3 patients operated in our institution was antrum preserving sleeve calibrated with a 36F bougie. We used 5 7 gold cartridges with no additional reinforcement by oversewing or buttress materials. For the other 5 patients who had their original LSG surgery performed in another hospital, the operative records were not found. The first patient had a history of gastric banding for 5 years and underwent sleeve and concomitant gastric band removal for weight loss failure (BMI ¼ 50 kg/ m 2 ) in another center. After 3.5 months, she was diagnosed with GF treated by peritoneal lavage and jejunostomy. The management of the GF was completed by a 28-mm endoscopic prosthesis-type Ultraflex (UltraflexTM Esophageal NG Stent System, Boston Scientific Corporation, Natick, MA) 10 days after. The removal of the prosthesis after 4 months was impossible because of the intense process of fibrosis. The endoscopic decision was to place in a second plastic prosthesis type Rusch (Willy Rusch GmbH, Teleflex Medical Company, Research Triangle Park, NC) for 15 days and to realize a complementary fulguration of the granulomatous tissue. After several failed attempts to remove the endoscopic prosthesis, another fistula was diagnosed in the lower part of the gastric tube. Facing multiple GFs and the impossibility of removing the prosthesis, we decided to perform a total with a Roux-en-Y esophagojejunal anastomosis. The second patient had an LSG in our institution complicated on postoperative day (POD) 17 by consecutive episodes of severe, intractable vomiting. The Gastrografin Table 1 Demographic data Age Initial intervention Time of diagnosis CT findings Initial management Endoscopic treatment Laparoscopic sleeve þ band removal Laparoscopic resleeve (Fig. 1) Laparoscopic sleeve þ band removal Laparoscopic sleeve Laparoscopic sleeve Laparoscopic sleeve Laparoscopic sleeve Laparoscopic sleeve 3.5 mo 6-cm collection Contrast extravasation positive Postoperative 8-cm collection Contrast day 5 extravasation positive Postoperative Multiple intraabdominal day 3 collections Contrast extravasation positive 14 mo 5-cm collection Contrast extravasation not mentioned 1 wk Intraabdominal collection * Contrast extravasation positive 4 wk 4-cm collection Contrast extravasation negative 3 wk 11-cm collection Contrast extravasation not mentioned 4 wk Intraabdominal collection * Contrast extravasation positive Peritoneal lavage laparotomy Peritoneal lavage/ laparotomy Endoscopy Stent impaction after 4 mo a second stent placed inside of the first 1 3 sessions of biologic glue Stent complicated by migration replacement of another 5 stents with 1 migration Stent 2 mo after replacement þ biologic glue Endoscopic clips þ prosthesis Endoscopic clips þ prosthesis Stent migration another stent þ biologic glue 2 mo after stent replacement 3 sessions of biologic glue * Not measured on the radiology report.

3 Chronic Fistula After Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 9 (2013) swallow and the upper endoscopy revealed the persistence of a residual gastric fundus resulting from incomplete dissection (Fig. 1). After 4 weeks of conservative treatment, we performed a resleeve complicated by fistula on POD 3, which necessitated drainage of the collection by. The patient was included in a protocol of serial endoscopic treatments by biologic glue. Six months later, because of the persistence of the fistula with no sign of healing despite multiple endoscopic sessions of biologic glue, the decision for a surgical approach was made. The third patient had undergone band removal and concomitant sleeve for weight loss failure in a different center (BMI ¼ 42 kg/m 2 ) after an 8-year history of inefficient gastric banding. The postoperative course was complicated 3 days later by a fistula, drained initially by laparotomy and secondarily by radiology on POD 8. After 15 days, he was transferred to our unit because of uncontrollable sepsis. Another laparotomy for drainage was performed with simultaneous feeding jejunostomy. One month afterward, an endoscopic prosthesis was inserted, which was complicated by the migration of the prosthesis. The patient moved to another region, and during the next 2.5 years, he had more than 40 endoscopic sessions and 6 prosthesis insertions, 2 of them complicated by migration. Because of the persistence of a high-output fistula and the inefficiency of the endoscopic treatment, a surgical approach was chosen. In all cases, the fistula was diagnosed by abdominal computed tomography with oral contrast Fig. 1. Technique There are 3 possible surgical procedures: gastrojejunal lateral anastomosis, Roux-en-Y gastric bypass, and with esojejunal anastomosis (Fig. 2). For types I and II, the anastomosis was performed on the fistulous orifice. Fig. 1. Control contrast study. Incomplete dissection of gastric fundus. The choice of the specific surgical procedure was based on the following variables: intraoperative findings, presence of perigastric abscess or multiple fistulas, and the anatomy of the gastric tube and fistula. Results After the initial management of the fistula, with good control of the sepsis by drainage and antibiotherapy, the endoscopic therapy was attempted for all 8 patients. Two patients had an initial treatment by endoscopic clips at 2 and 7 months, with recurrence of the leakage, followed by endoscopic stents. The first patient presented with an intraabdominal collection with the prosthesis in place; therefore, the stent was removed. The second patient presented with a migration of the prosthesis; the second prosthesis was changed after 3 months. Two other patients had the endoscopic stent as the first choice treatment (Fig. 3): in the first case at the same time with the peritoneal lavage and in the second case 10 days postoperatively. In the first case, the prosthesis was impossible to remove after 4 months, and a second fistulous orifice was diagnosed at the lower part of the stent. A second plastic stent was placed inside of the first one. Both stents were removed 7 months after the diagnosis of the fistula during the reconstructive surgery by with esophagojejunal anastomosis. In the second case, the stent was changed after 3 months. After the second stent s removal, because of the persistent fistula, it was decided to use sequential endoscopic sessions with sealing glue. After 14 months, the output of the fistula was constantly high and reconstructive surgery was performed. In 2 other patients the fibrin sealant Beriplast (Beriplast, CSL Behring GmbH, Marburg, Lahn) was used as a tissue adhesive. In both patients, we had signs that the defect continued to exist, so multiple applications were performed. For both patients, the output of the fistula remained 5 months after diagnosis, and the decision for reconstructive surgery was made. The last 2 patients had a sequential treatment with glue and prosthesis. The overall average diagnosis time of the fistula was 14.4 months (range 5 44 months). The surgical procedures (Fig. 2) performed for chronic fistula after sleeve were (1) gastrojejunal lateral anastomosis in 4 cases, (2) Roux-en-Y gastric bypass in 2 cases, (3) and with esojejunal anastomosis in 2 cases. The intraoperative time for all 8 patients is illustrated in Table 2. The mean operative time was 193 minutes (range minutes). All procedures were performed by laparotomy. For the last patient, the laparoscopic approach was attempted, but conversion was necessary because of the intense adhesions between the posterior part of the gastric tube and the anterior part of the pancreas. The postoperative fistula was recorded for 4 patients: 3 patients had early leaks, and only 1 patient had a late

4 882 A. M. Nedelcu et al. / Surgery for Obesity and Related Diseases 9 (2013) Table 2 Operative time leak 41 week after surgery. The mean healing time of the fistula was 32 days (range days). None of these patients needed another surgical procedure for drainage, 3 patients had an early leak with the drain already in place, and the fourth patient had radiological drainage. Two patients required admittance to the intensive care unit for respiratory problems. No mortality was recorded. Discussion LSG has increasingly gained worldwide acceptance among bariatric surgeons during the past 7 years. Initially, LSG was accepted as a first-stage procedure in high-risk or super-obese patients, but the popularity of the procedure increased as it started to be used as a single-stage procedure. Despite the above, the procedure has been associated with specific and life-threatening complications, the most feared being GF. A new problem occurs for high-activity bariatric centers the management of the chronic gastric leak. The literature does not offer a clear definition for the chronic gastric leak or its treatment. In our experience, we start considering chronic gastric leak after 6 weeks of diagnosis with remission of major inflammatory signs with constant output. We propose reconstructive surgical treatment when all endoscopic approaches have failed to close the fistula. When faced with a GF, the surgeon must consider all options to confront it adequately. Upon the establishment of the diagnosis of a GF, blood and electrolyte imbalance restoration, alimentary tract resting, optimal nutrition launching, and sepsis management must be an absolute priority. Then we should proceed to the endoscopic exploration of the gastricareatoassessfordifferentmethodsofendoscopic treatment. The use of coated self-expandable stents in the treatment of leakage after bariatric operations appears to be practical and reliable, as was shown in several studies [11 19], but this is often complicated by migration of the prosthesis, or if not, it has to be removed or changed 2 3 months after its placement. Also endoscopic sealing glue should be considered as an option of treatment as proven in several studies. Alternatively, the applications of endoscopic clips are suggested. Endoscopic clip application is considered successful when no leakage occurs for a minimum of 3 days. After initial successful management of the sepsis, patients with gastric leak are referred to the endoscopic unit. In this way, 40 of 54 (74.04%) patients with fistula as a complication after sleeve have healed by Fig. 2. Types of surgical procedures: (1) gastrojejunal anastomosis, (2) Roux-en-Y gastric bypass, (3) with esojejunal anastomosis.

5 Chronic Fistula After Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 9 (2013) Fig. 3. Stent placement. Correct position after stent placement. different endoscopic approaches, including endoprothese, endoscopic clips, endoscopic sealing glue, or balloon dilation. These patients were included in a multicenter study. Calculating an exact rate for each of these approaches was impossible because of the use of multiple approaches for each patient. In our experience, the successful use of the endoprothese is very limited when the leak diagnosis is done 41 month postoperatively. This explains the nonuse of stents in some of the patients. Of 54 patients, 6 achieved the healing of the leak by medical treatment with no therapeutic endoscopic procedure. The other 8 patients, with persistent leak despite aggressive endoscopic approach, were referred for surgical treatment, and they represent the subject of this report. In patients in whom all the aforementioned conservative techniques fail, aggressive management with surgical reconstructive procedures may be performed. Only a few reports on the surgical treatment of chronic gastric leak were found [6 10]. The first case in the literature was described by Baltasar et al. in 2007 [7]. They presented the case of a 48-year-old woman who developed a GF at POD 3 after LSG surgery and was treated by conservative measures. Six weeks after the original surgery, a Roux-en-Y limb was brought to the esogastric junction and anastomosed side-to-end to the fistula. At the beginning, the Roux limb was the only functioning outlet, and finally, 2 months later, both pathways (the gastric sleeve and the Roux-en-Y) were patent. No fistula occurred in that patient. The same team reported 1 year previously, in another article [10], a series of 9 cases of total gastrectomies out of 846 patients who underwent the duodenal switch for different complications 5 cases resulting from gastric leak at the angle of His. No mortality was recorded, but the hospital stay was long in all patients (mean 4.5 months; range 1 10 months) J.M. Regimbeau et al. [6] reported in Journal de chirurgie a case of chronic fistula after sleeve treated with Roux-en-Y loop anastomosis to esogastric junction. A 54-year-old female was treated initially for morbid obesity with gastric banding, which was removed 2 years later because of slippage. After 5 years, an LSG was performed and was complicated by a fistula diagnosed at POD 1. During the surgical reintervention, a suture of the fistula was tried, but the postoperative course showed the persistence of the leak. Four endoscopic sessions were attempted with prosthesis, clips, or sealing glue. At POD 79, the reconstructive surgery was performed with Roux-en-Y loop anastomosis to esogastric junction with feeding jejunostomy. The realimentation was started at POD 9, and no fistula occurred. Tan et al. [8] published their results on the management of gastric leaks, mentioning 2 cases of reconstructive surgery. A 51-year-old female had an open sleeve (a few months after gastric band removal) complicated by high-output fistula at POD 3, which was treated with a covered stent. Because of the persistence of sepsis, a return to the operative room was necessary at POD 7, when a large 3-cm defect was found in the body of the stomach in the anterior wall and was closed with a jejunal serosal patch. Postoperatively, the patient developed a small leak, but this resolved with conservative management. The second patient, a 53-year-old woman who previously had a vertical banded gastroplasty underwent LSG complicated by a fistula. Despite 2 laparotomies for drainage and 2 endoscopic attempts with covered stents, she continued to have a high-output gastrocutaneous fistula even after a year. During the third laparotomy, the intraoperative findings were 3 breaches in her gastric staple line leading to the fistula and the back of the stomach firmly adherent to the pancreas. The decision was to disconnect the esophagus from the stomach, perform a Roux-en-Y esophagojejunostomy, and intubate the holes in the stomach with T-tubes. The patient developed a small leak at the esophagojejunostomy, but this was settled, too, with conservative management. Conclusion It is important that patients be treated in a center with full intensive care, as well as gastroenterological and radiological back-up. As a last resort, salvage reconstructive surgery also should be in the armamentarium of the bariatric surgeons. We consider redo surgery from gastric banding to sleeve acceptable, even against the principle restriction after restriction, because of good results at mid-term follow-up and improvement in quality of life. Several centers perform this surgery in a single operative session. In our experience, because of the frequency of complications, we prefer 2 different procedures separated by 3 to 6 months. In this period, the patient can be evaluated by the psychologist and dietician. There is no consensus on

6 884 A. M. Nedelcu et al. / Surgery for Obesity and Related Diseases 9 (2013) whether to perform the conversion 1 or 2 times, but our recommendation is to perform it 2 times. More prospective, randomized trials are needed to draw out definitive conclusions regarding the efficacy of the surgical treatment for chronic fistula after sleeve compared with the endoscopic approach. No endoscopic approach has proved efficacy in the treatment of chronic gastric leak after LSG with a high level of evidence. References [1] Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25 27, Obes Surg 2008;18: [2] Lee CM, Cirangle PT, Jossart GH. Vertical for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21: [3] Nocca D, Krawczyowsky D, Bomans B, et al. A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Obes Surg 2008;18: [4] Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve : a prospective study in 135 patients with morbid obesity. Surgery 2009;145: [5] Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve : results after 1 and 3 years. Obes Surg 2006;16: [6] Regimbeau JM, Verhaeghe P, Fuks D, et al. Traitement d une fistule chronique post sleeve gastrectomie par une anse en Y. Journal de Chirurgie Viscérale 2010;147:71 4. [7] Baltasar A, Bou R, Bengochea M, Serra C, Cipagauta L. Use of a Roux limb to correct esophago-gastric junction fistulas after sleeve. Obes Surg 2007;17: [8] Tan JT, Kariyawasam S, Wijeratne T, Chandraratna HS. Diagnosis and management of gastric leaks after laparoscopic sleeve for morbid obesity. Obes Surg 2009;20: [9] Fuks D, Dumont F, Berna P, et al. Case report complex management of a postoperative bronchogastric fistula after laparoscopic sleeve. Obes Surg 2009;19: [10] Serra C, Baltasar A, Perez N, Bou R, Bengochea M. Total for complications of the duodenal switch, with reversal. Obes Surg 2006;16: [11] Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve and gastric bypass: endoscopic management and prevention. Obes Surg 2011;21: [12] Serra C, Baltasar A, Andreo L, et al. Treatment of gastric leaks with coated self expanding stents after sleeve. Obes Surg 2007;17: [13] Salinas A, Baptista A, Santiago E, Antor M, Salinas H. Self expandable metal stents to treat gastric leaks. Surg Obes Relat Dis 2006;2: [14] Nguyen NT, Nguyen XM, Dholakia C. The use of endoscopic stent in management of leaks after sleeve. Obes Surg 2010;20: [15] Fukumoto R, Orlina J, McGinty J, Teixeira J. Use of Polyflex stents in the treatment of acute esophageal and gastric leaks after bariatric surgery. Surg Obes Relat Dis 2007;3: [16] Casella G, Soricelli E, Rizzello M, et al. Nonsurgical treatment of staple line leaks after laparoscopic sleeve. Obes Surg 2009;19: [17] Oshiro T, Kasama K, Umezawa A, Kanehira E, Kurokawa Y. Successful management of refractory staple line leakage at the esogastric junction after sleeve using a HANAROS- TENT. Obes Surg 2010;20: [18] Eisendrath P, Cremer M, Himpens J, Cadiere GB, Le Moine O, Deviere J. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy 2007;39: [19] Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg 2008;206:935 8.