Refractory complex gastrobroncho-cutaneous fistula after laparoscopic sleeve gastrectomy: a novel technique for endoscopic management.

Laparoscopic sleeve gastrectomy (LSG) is a widely used, effective stand-alone procedure for treatment of morbid obesity [[1]Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. Position statement: sleeve gastrectomy as a bariatric procedure.Surg Obes Relat Dis. 2007; 3: 573-576Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar]. However, it is a procedure not without complications [2Brethauer S.A. Hammel J.P. Schauer P.R. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure.Surg Obes Relat Dis. 2009; 5: 469-475Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar, 3Benaiges D. Más-Lorenzo A. Goday A. Ramon J.M. Chillarón J.J. Pedro-Botet J. Roux J.A. Laparoscopic sleeve gastrectomy: more than a restrictive bariatric surgery procedure?.World J Gastroenterol. 2015; 21: 11804-11814Crossref PubMed Scopus (126) Google Scholar]. Staple-line leakage is the most serious complication after primary LSG, with an incidence of 1.4% to 4% [4Aurora A.R. Khaitan L. Saber A.A. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.Surg Endosc. 2012; 26: 1509-1515Crossref PubMed Scopus (407) Google Scholar, 5Soufron J. Leak or fistula after sleeve gastrectomy: treatment with pigtail drain by the rendezvous technique.Obes Surg. 2015; 25: 1979-1980Crossref PubMed Scopus (13) Google Scholar, 6Yaacov A.B. Sadot E. David M.B. Wasserberg N. Keidar A. Laparoscopic total gastrectomy with Roux-Y esophagojejunostomy for chronic gastric fistula after laparoscopic sleeve gastrectomy.Obes Surg. 2014; 24: 425-429Crossref Scopus (21) Google Scholar]. In rare cases, chronic proximal gastric leakage transforms into gastrobronchial fistula [[7]Guillaud A. Moszkowicz D. Nedelcu M. et al.Gastrobronchial fistula: a serious complication of sleeve gastrectomy. Results of a French multicentric study.Obes Surg. 2015; 25: 2352-2359Crossref PubMed Scopus (22) Google Scholar]. Factors associated with the occurrence and persistence of gastric fistula include distal stenosis, twisted gastric tube, intragastric hypertension, stapling and ischemia at lower esophagus, multiple comorbidities, and super obesity [[8]Baretta G. Campos J. Correia S. et al.Bariatric postoperative fistula: a life-saving endoscopic procedure.Surg Endosc. 2015; 29: 1714-1720Crossref PubMed Scopus (45) Google Scholar]. Various techniques have been described for treatment of gastric fistulae after LSG. Endoscopic approach is the primary line of treatment reported [[9]Puli S.R. Spofford I.S. Thompson C.C. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis.Gastrointest Endosc. 2012; 75: 287-293Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar]. Endoscopic procedures include application of self-expanding metallic stents, balloon dilation of distal stricture, and stricturotomy [[8]Baretta G. Campos J. Correia S. et al.Bariatric postoperative fistula: a life-saving endoscopic procedure.Surg Endosc. 2015; 29: 1714-1720Crossref PubMed Scopus (45) Google Scholar]. Reoperation for treatment of gastric fistula after LSG is indicated for chronic and refractory fistulae and is associated with higher morbidity and mortality [[10]Vilallonga R. Himpens J. Vrande S. Laparoscopic management of persistent strictures after laparoscopic sleeve gastrectomy.Obes Surg. 2013; 23: 1655-1661Crossref PubMed Scopus (46) Google Scholar]. Surgical procedures include surgical drainage, total gastrectomy, Roux-en-Y esophagojejunostomy, Roux-en-Y gastrojejunostomy, and fistulojejunostomy [6Yaacov A.B. Sadot E. David M.B. Wasserberg N. Keidar A. Laparoscopic total gastrectomy with Roux-Y esophagojejunostomy for chronic gastric fistula after laparoscopic sleeve gastrectomy.Obes Surg. 2014; 24: 425-429Crossref Scopus (21) Google Scholar, 11Vilallonga R. Himpens J. Vrande S. Laparoscopic Roux limb placement for the management of chronic proximal fistulas after sleeve gastrectomy: technical aspects.Surg Endosc. 2015; 29: 414-416Crossref PubMed Scopus (17) Google Scholar]. A hybrid endoscopic and surgical technique is reported by many authors. In this article, we describe a novel endoscopic technique that was successful in management of a chronic gastrobronchial fistula and explain its merits and benefits. The patient described in the present case report was a 34-year-old male who underwent LSG in another facility when his body mass index was 44 kg/m2 without comorbidities. Early leakage was diagnosed on the third postoperative day and managed by laparoscopic drainage and endoscopic insertion of self-expanding, fully covered stent. Two days later, intraperitoneal hemorrhage and hemothorax occurred; this was managed by cessation of anticoagulant, insertion of an intercostal tube, and laparotomy, which revealed no definite source of bleeding. Then the intercostal tube became obstructed, and the case was managed by thoracotomy, evacuation of hematoma, and insertion of 2 intercostal tubes. One month later, the esophageal stent was removed. After removal of the stent, gastrobroncho-cutaneous fistula (GBCF) through the thoracotomy scar became evident (Fig. 1). Abdominal computed tomography revealed bilateral subphrenic collection. This was managed by ultrasound-guided tube drainage of the left and right subphrenic collections and endoscopic insertion of an esophageal stent (15 cm) that failed to stop leakage. The patient was referred to us 1.5 months after the primary surgery. On examination, the patient showed signs of toxemia in the form of tachycardia (110–120 beats/min), dyspnea, generalized weakness, and fatigability. The thoracotomy scar was discharging pus through multiple orifices. Contrast study revealed a GBCF connected to the gastroesophageal junction. Upper endoscopy revealed a wide internal opening of the GBCF with the upper part of the stent twisted inside its opening. The migrated stent was removed, and a fully covered, self-expanding stent (Taewoong Niti-S Megastent, Taewoong Medical, Korea) was inserted. The fistulous output decreased, and oral intake was started 24 hours after stent insertion. One week later, fistulous output increased dramatically, and endoscopy revealed a downward-migrated stent. Repositioning was performed. Three days later, remigration occurred. Parenteral nutrition was not possible due to difficult access to peripheral and central veins, even with the efforts of 2 expert intensive care unit anesthesiologists. The condition was managed by endoscopic repositioning of the stent with insertion of a Sengstaken-Blakemore (SB) tube (18 French) through the stent; the stent tip was placed in the duodenum, the gastric balloon below the stent, and the esophageal balloon inside the stent. The tube was inserted through the patient’s nose and pulled through the mouth, and was grasped by rat-tooth forceps (Endo-Flex, Germany) through the channel of the gastroscope. The tube tip was navigated through the stent downward to the second part of the duodenum. Then a Savary guidewire (Wilson-Cook Medical Inc., Winston Salem, NC) was introduced through the feeding channel until it could be seen though the holes at the end of the tube. The rationale for using this guidewire was to allow withdrawal of the scope and grasper without pulling out the tube again (Fig. 2). The gastric and esophageal balloons were inflated with saline up to 20 mm Hg under direct endoscopic vision. Enteral feeding through the tube was started a few hours later. In the following days, oral contrast study revealed persistent leakage. This was managed with balloon deflation, gradual pull-up of the tube, and reinflation using saline until leakage was determined under fluoroscopic guidance to have stopped (Fig. 3). Once the balloon was correctly placed and no further leakage was evident on fluoroscopy, both balloons were further inflated to a pressure of 25 mm Hg. Discharge from 2 cutaneous fistulae stopped completely 2 days after optimum repositioning. Gradual saline inflation of the esophageal balloon, up to 50 mm Hg, was done every 3 days, while the gastric balloon was kept inflated up to 25 mm Hg by saline. The SB tube was blocked and removed after 18 days. Contrast study revealed absence of leakage (Fig. 4). The stent was removed 1 month later, followed by endoscopic dilation for a stricture at the incisures using a 3.5 cm achalasia balloon (Achalasie-Ballon, Endo-Flex, Germany). Endoscopic dilation of the stricture was repeated every 2 weeks using achalasia balloon (4 cm) a total of 3 times. The patient regained health, and toxemic manifestations subsided. Serial follow-up contrast studies revealed fistula closure. GBCF is a serious complication after different bariatric procedures [12Silva L.B. Moon R.C. Teixeira A.F. et al.Gastrobronchial fistula in sleeve gastrectomy and Roux-en-Y gastric bypass—a systematic review.Obes Surg. 2015; 25: 1959-1965Crossref Scopus (24) Google Scholar, 13Chin P.L. Gastrobronchial fistula as a complication of a laparoscopic adjustable gastric banding.Surg Obes Relat Dis. 2008; 4: 671-673Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] and is associated with high morbidity and mortality [[14]Li Y.D. Li M.H. Han X.W. Wu G. Li W.B. Gastrotracheal and gastrobronchial fistulas: management with covered expandable metallic stents.J Vasc Interv Radiol. 2006; 17: 1649-1656Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. Its actual incidence is not known. Treatment of chronic fistulae is challenging, and major reoperation is usually necessary [[15]Barreca M. Nagliati C. Jain V.K. Whitelaw D.E. Combined endoscopic laparoscopic T-tube insertion for the treatment of staple-line leak after sleeve gastrectomy: a simple and effective therapeutic option.Surg Obes Relat Dis. 2014; 11: 479-482Abstract Full Text Full Text PDF Scopus (9) Google Scholar]. In this report, we present our experience with a novel technique for management of chronic, refractory GBCF by endoscopic placement of a fully covered, self-expandable stent (Endo-Flex, Germany) and SB tube. Endoscopic insertion of SB tube is demanding and requires adequate experience in endoscopic techniques. The use of rat-tooth forceps allowed firm grasping of the SB tube without slippage. The hard shaft allowed easy direction of the tube; malleability would lead to difficult progress through the alimentary lumen. Insertion of the Savary guidewire facilitated easy withdrawal of the scope and forceps without slippage from the tube after its placement. The use of the SB tube had many advantages. It prevented stent migration, one of the most frequent complications after stent placement. Migration was further controlled by placement of the gastric balloon in the antrum below the stent and the esophageal balloon inside the stent. Another advantage of using the SB tube was that inflation of the esophageal balloon led to coaptation of the stent with the esophageal wall, with complete plugging of the internal fistulous opening. This prevented leakage of fluids and saliva into the space between the stent and the esophageal wall, helping to prevent persistent fistula. Gradual inflation of the esophageal balloon over a period of more than 2 weeks led to gradual dilation of the gastric stricture, which is a main contributing factor in persistent fistula. To avoid affecting blood supply to the lower esophagus, the esophageal balloon was not inflated beyond a pressure of 50 mm Hg. We used saline instead of air for inflation in order to avoid leakage of air and maintain adequate pressure on the stent; inadequate pressure exertion on the stent would prevent full coaptation with the esophageal wall. There was no suction port in the tube proximal to the esophageal balloon, so the patient had to spit saliva regularly. We think that using a 4 lumen tube with 1 tube for suction of the secretions above the esophageal balloon might be a better approach, but it was not available in our institute at the time of management. One of the main concerns during management of staple-line leakage after LSG is adequate feeding. In the reported case, there was a true dilemma regarding patient feeding. Access to peripheral and central veins to allow parenteral nutrition was not possible. Creation of a surgical feeding jejunostomy was hazardous because of previous surgical explorations with the associated adhesions and increased likelihood of complications. The SB tube allowed enteral feeding by conveying nutrients in addition to controlling the fistulous track. Its advantage over nasogastric tube feeding is that it prevented reflux of nutrients via the inflated gastric balloon. In conclusion, endoscopic stenting with SB tube placement was a safe and successful technique for management of this case of refractory leakage complicated by GBCF after LSG. Further studies on a larger sample are required to explore the validity and drawbacks of this technique in comparison with other treatment strategies. The authors have no commercial associations that might be a conflict of interest in relation to this article.