Multimodal Endoscopic Management of Fistula after Sleeve Gastrectomy Involving a Novel Esophageal Stent

Abstract

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a bariatric surgical procedure associated with a non-negligible risk of postoperative adverse events, especially fistulas, the majority of which occur at the angle of His. This adverse event requires a multidisciplinary approach involving intensive care, surgery, interventional endoscopy, and radiology. Despite the absence of an algorithmic endoscopic approach, a primarily endoscopic management of fistulas after LSG is now standard of care in most institutions. Case Report: A 66-year-old female with grade III obesity, obstructive sleep apnea, type 2 diabetes, and hypertension underwent LSG. She developed abdominal pain, hypovolemic shock, and severe anemia (Hb 6.5 g/dL). A computed tomography (CT) scan revealed hemoperitoneum without active bleeding, managed with transfusion of packed blood cells. A week later, a new CT scan performed for leukocytosis and abdominal pain revealed pneumoperitoneum. An esophagogastroduodenoscopy revealed a 20-mm fistula orifice at the angle of His. A novel esophageal covered metallic stent was placed for a period of 5 weeks. The fistula orifice decreased to 4 mm and communicated through a fistulous tract with a residual subphrenic abscess measuring 62 × 20 mm. Pus was collected from the abscess and drained internally with a 10-Fr double pigtail plastic stent through the fistula orifice. Following an initial period of improvement, clinical deterioration required percutaneous subphrenic abscess drainage. Two weeks later, the double pigtail plastic stent was removed, the fistula orifice was ablated with argon plasma 40W/1L and closed with an over-the-scope clip of 10 mm. Patient improved and was discharged 4 months after the LSG. Conclusion: The Luso-Cor esophageal stent is a specifically designed covered metallic stent with a 5-mm uncovered ring near the proximal edge, which reduces the risk of migration. Two articulating zones in the middle portion allow better adaptation to altered anatomy after LSG and a distal flare reduces retrograde reflux of fluid. This stent overcomes strictures in the gastric tube, concomitantly present in nearly 50% of patients with fistulas after LSG. The novel Luso-Cor esophageal stent provided a bridge to clinical stability with a significant reduction in the size of the fistula orifice which was closed with complementary therapeutic endoscopic procedures.