10- management of anastomotic complications from bariatric surgery

Background

Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding.

Objective

To assess a new, totally endoscopic strategy to manage anastomotic fistulas.

Design

Prospective study.

Setting

Tertiary-care university hospital.

Patients

This study involved 27 consecutive patients from July 2007 to December 2009.

Intervention

This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant.

Main Outcome Measurements

Technical success, mortality and morbidity, migration of the stent.

Results

Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient.

Limitations

Moderate sample size, nonrandomized study.

Conclusion

An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery—using sequential drainage, sutures, and diversion by stents—achieved resolution of the fistulas with minimal morbidity.

keywords:

BMI (body mass index), NOTES (natural endoscopic transluminal endoscopic surgery)