Endoscopic Closure of a Multifocal Leak From a Gastric Sleeve

Abstract

Case Report: A 41-year-old male with gastric sleeve procedure 6 months prior presented with abdominal abscesses. Upper endoscopy showed fistulous tracts: site 2 and site 3. Site 2 fistula took a 180° turn traveling retrograde to gastroesophageal junction (GEJ). Argon plasma coagulation was applied to both tracts, followed by 10 cc of Tisseel, a fibrin sealant. Repeat endoscopic fistulogram revealed a persistent leak. Cautery was applied to site 2 with 5 cc Tisseel. Glue was seen extruding from site 3 confirming communication. Repeat EGD showed a new fistula, site 1, at GEJ and closed site 3 fistula. Two cc Tisseel was injected and it extruded from site 2. Follow-up EGD showed a smaller site 1 tract and repeat cautery, and Tisseel injection was applied. The patient continues to undergo endoscopic surveillance and management of the fistulae. Discussion: This is a case of common, but one of the most challenging, complications of sleeve gastrectomy, responsible for approximately 50% of deaths. Gastric leaks are affected by high intragastric pressure. Minimally invasive endoscopic techniques, use of glue or stent placement, are effective. This case was interesting due to its multifocal nature of communication between the fistulae. Through continued effective endoscopic maneuvers, we demonstrated adequate closure of a multifocal leak from a gastric sleeve.Figure 1: Fistula tract.Figure 2: Fluoro picture demonstrates communicating Fistula 2 and Fistula 3.Figure 3: APC ablation.