The usage of an endoscopically inserted double-J stent to treat a gastro-cutaneous fistula following bariatric surgery in a young patient: A case report

Abstract

Gastro-cutaneous fistula (GCF) is an infrequent and catastrophic complication following bariatric and metabolic surgery (BMS). Different treatment modalities have been employed for the closure of GCF. Therapeutic options for GCF are classified into 3 categories: medical, endoscopic and surgical. Conservative management includes antibiotics, bowel rest, parenteral nutrition and adequate drainage. Stenting, tissue sealants, over-the-scope clips (OTSC) and suturing are endoscopic modalities. Total or sub-total gastrectomy and revisional surgery fall into the category of surgical treatment. We herein present a case of a 26-year-old female patient, morbidly obese, whose bariatric surgery was complicated by the formation of GCF. Patient failed a trial of medical treatment because she had persistent fevers, abdominal discomfort and a high-output fistula (> 500 mL/day). In light of this, endoscopic modality was employed through the insertion of a full-length double-J stent. The GCF was identified right below the gastroesophageal junction. The double-J stent was advanced over the guidewire and properly inserted under endoscopic and fluoroscopic guidance. The stent works by concealing the area of leakage and redirecting gastrointestinal secretions away from the fistulous tract. The rationale behind choosing a double-J stent over other endoscopic options is that it has curving ends, which mitigates the risk of stent migration. A plastic double-J stent is more cost-effective than metallic stents. 48 hours post-procedure, KUB radiography revealed no extravasation of contrast media and patient was started on soft diet. Patient well-tolerated soft diet; therefore, she was advanced to regular diet at day 7 post-stent insertion. After 6 weeks, a repeat KUB radiography revealed proper placement of the double-J stent. Subsequently, an upper endoscopy was performed after which the double-J stent was successfully removed. 72 hours post-stent extraction, an oral gastrografin radiography revealed no extravasation or leakage of contrast media, indicating a complete closure of GCF. The patient’s clinical condition significantly improved after re-introduction of oral feeding and she was able to resume her daily-life activities. This article underscores the safety and efficacy of using a double-J stent to treat GCF. It also brings about future implications regarding the potentiality of incorporating double-J stents into endoscopic options used for GCF closure.