Severe Dehiscence of Gastrojejunal Anastomosis after Gastric Bypass: Its Cure by Using Partially Covered Stent and Avoiding Migration.

Abstract

Gastric leak is a severe complication of gastric bypass that is associated with significant morbidity and mortality. Anastomosis dehiscence usually occurs at gastrojejunal anastomosis and can appear simultaneously with gastric leak, for which treatment can be a challenge. Fistula may have several clinical impacts, depending on patient-related factors, fistula characteristics, onset time, and therapy proposal. Abdominal toilet, drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. Currently, endoscopic stents are gaining space, promoting fistula sealing, secretion deviation, treating gastric stricture, and allowing early oral diet. Herein, we present a case of severe gastrojejunal anastomosis dehiscence treated with partially covered stent. We present a video of a 39-year-old man with a body mass index of 40Kg/m2 who underwent a Roux-en-Y gastric bypass and presented fever and leukocytosis. Gastric leak was diagnosed 7days after the bariatric surgery. At first, he was submitted to three reoperations: laparotomy with abdominal toilet, abdominal drain, and gastrostomy. Sepsis was controlled, but drain output maintained the same debit. On the 22nd POD, it was decided to place a metallic stent. As the first step, an endoscopist looked at the lesser curvature. There was no continuity to the alimentary limb, and the anastomosis was disrupted. Careful inflation and washing was done, allowing identification of the alimentary limb, followed by guidewire passage, with radioscopic control. Once the guidewire was positioned, stent placement was possible and safe. Upper edge of stent was placed in the lower third of the esophagus. Patient progressed uneventfully. After 4weeks, stent removal was attempted. However, it was not possible due to endoluminal tissue hyperplasia. Argon plasma was used three times to promote proliferative mucosa ablation. Stent was removed after 53days, with no migration. The abdominal drain was removed 1week later. After 6-months follow-up, the patient remains asymptomatic. Early dehiscence closure was observed, without recurrence. The use of partially covered self-expandable metallic stent is associated with lower migration rates; however, removal can be technically difficult due to tissue hyperplasia.