Abstract
PurposePost-bariatric surgery gastrocutaneous fistula is a chronic leak with an incidence of 1.7 to 4.0% and no standardized management. A large gastrocutaneous fistula (LGCF) is not indicated for treatment with pigtail drains. We aimed to evaluate results of a novel treatment using endoscopic Kehr’s T-tube placement.MethodsOnly patients with a postoperative LGCF duration of > 10 days and a flow rate of > 50 cc by external drainage after revisional surgery for sepsis were included. Endoscopic placement of Kehr’s T-tube was performed. Patients had been reoperated with wash and drainage for severe sepsis after initial bariatric surgery in which no fistula had been discovered. Patients not reoperated, or with a fistula requiring intraoperative Kehr’s T-tube placement, or a pigtail drain were excluded. Primary outcomes were endoscopic characteristics and results (LGCF closure rate, Kehr T-tube retention time, etc.).ResultsThe study group included 12 women, 2 men; body mass index 43.1 ± 4.5 kg/m2. Interventions were SG (7), RYGB (2), OAGB (4), and SADI-S (1). Endoscopic assessment was carried out after a mean of 33.2 ± 44.3 days after the bariatric procedure. The mean fistula orifice diameter was 2.0 ± 0.9 cm. Kehr’s T-tube was positioned at a mean 51.5 ± 54.8 days after the bariatric procedure. T-tube tolerance was excellent. Mean additional days: hospitalization, 34.4 ± 27.0; T-tube retention, 86.4 ± 73.1; fistula healing, 139.9 ± 111.5, LGCF closure rate, 92.9%. Complications: 1 pulmonary embolism, 2 T-tube migrations,1 drain-path bleed, 1 skin abscess. No mortality.ConclusionsEndoscopic Kehr’s T-tube placement was successful in closing persistent post-bariatric surgery LGCF in 92.9% of patients.Graphical abstract
Highlights
Bariatric procedures affect significant weight loss and comorbidity reduction with a low mortality (0.1%) and overall complications of around 4.0% [1]
A recent American Society for Metabolic and Bariatric Surgery statement suggests that available data do not favor one leak closure treatment over another [6]
We examined outcomes of all persistent large gastrocutaneous fistula (LGCF) treated with this novel methodology following oneanastomosis gastric bypass (OAGB), SG, Roux-en-Y gastric bypass (RYGB), and single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S)
Summary
Bariatric procedures affect significant weight loss and comorbidity reduction with a low mortality (0.1%) and overall complications of around 4.0% [1]. Leak leading to abscess or fistula collection is a major adverse event. A conservative nonsurgical endoscopic or radiological approach is usually effective in managing smaller leaks in the short term; a chronic large-diameter leak with a fistulous tract is extremely challenging to resolve and may require surgery and extended hospitalization [2]. A recent American Society for Metabolic and Bariatric Surgery statement suggests that available data do not favor one leak closure treatment over another [6]. Pigtail drains are often employed as the solution for small leak management but are often ineffective in large-diameter leak resolution (Fig. 1). Primary closure of chronic fistulas with ≥ 2-cm orifices is often unsuccessful, and there is no standardized endoscopic approach [8]
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