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Obesity Surgery (2018) 28:1456–1457


Endoscopic Fistula-jejunostomy for Chronic Gastro-jejunal Fistula

After Sleeve Gastrectomy
Gianfranco Donatelli 1 & Ludovica Guerriero 1,2 & Fabrizio Cereatti 3 & Kostantinos Arapis 4 & Carmelisa Dammaro 5,6 &
Jean-Loup Dumont 1 & David Fuks 7 & Silvana Perretta 2

Published online: 9 March 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Introduction Proximal gastric leak is one of the most common complications after laparoscopic sleeve gastrectomy (LSG).
Endoscopy is the gold standard treatment for acute staple-line leaks. Surgery is the most effective treatment modality in case
of chronic fistula.
Material and Methods A 55-year- old man presented an acute leak after LSG. The leak was treated with metal stent deployment
with temporary closure. After 6 months, he presented leak recurrence with general sepsis, perigastric-infected collection, and
gastro-jejunal fistula.
Results Endoscopic internal drainage (EID) was performed; however, due to fistula persistence, a surgical procedure was
proposed. The patient refused revisional surgery; therefore, endoscopic salvage procedure was decided. A fully covered metal
stent was deployed in order to bypass the perigastric collection creating an endoscopic gastro-jejunal anastomosis.
Conclusion Revisional surgery is the gold standard treatment for chronic fistula after SG. Endoscopic treatment with SEMS deploy-
ment may be a sound option in selected cases especially after failure of other endoscopic techniques or refusal of revisional surgery.

Keywords Sleeve gastrectomy . Leak . Fistula . EID . SEMS . Complications . By-pass . Fistula-jejunostomy


Laparoscopic sleeve gastrectomy (LSG) is the most frequent

Electronic supplementary material The online version of this article
( contains supplementary bariatric procedure for morbid obesity with good short-term
material, which is available to authorized users. results and an overall morbidity rate lower than other bariatric
procedures [1].
* Gianfranco Donatelli Proximal gastric leak is the most frequent adverse event after LSG with a reported incidence ranging from 1.1 to 7%
of the cases [2, 3]. Leaks are mainly located in the upper third
Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, of the staple-line just below the angle of His.
Hôpital Privé des Peupliers, 8 Place de l’Abbé G. Hénocque, Acute leaks may be successfully treated with different en-
75013 Paris, France
doscopic techniques whereas chronic fistulas are rarely cured
IRCAD/IHU-Institute of Image-Guided Surgery, 1 Place de by endoscopic procedure often requiring revisional surgery.
l’Hopital, 67000 Strasbourg, France
Digestive Endoscopy and Gastroenterology Unit, A.O. Istituti
Ospitalieri di Cremona, Cremona, Italy
Department of General and Visceral Surgery, Bichat-Claude Bernard Material and Methods
University Hospital, Paris, France
Department of Minimally Invasive Digestive Surgery, A 55-year-old man with a BMI of 45 underwent LSG. No
Antoine-Beclere Hospital, AP-, F-92140 Clamart, HP, France buttresses of the staple line was performed. At post-
Paris-Saclay University, F-91405 Orsay, France operative day 4, dehiscence of proximal staple line was
Department of Digestive Surgery, Institut Mutualiste Montsouris, highlighted. The leak was treated with deployment of a fully
75014 Paris, France covered self expandable metal stent (SEMS). Temporary
OBES SURG (2018) 28:1456–1457 1457

fistula sealing was achieved. After 6 months, the patient de- jejunostomy has been proposed as an effective and less inva-
veloped diffuse peritonitis and sepsis requiring hospital ad- sive option compared to total gastrectomy [7]. Endoscopic
mission. At a local hospital, there was no availability of inter- fistula-jejunostomy by by-passing the fistula with insertion
ventional radiology; therefore, surgical procedure was per- of fully covered SEMS, as we show in this case, could be
formed. At laparotomy, chronic gastric leak with concomitant considered a viable option in well selected patients especially
infected abscess was highlighted, and a surgical drainage was when other endoscopic treatments fail or surgery is refused.
deployed close to staple line.
Three days from surgery, endoscopic internal drain- Compliance with Ethical Standards
age (EID) with insertion of double-pigtail stents across
the leak was performed [4]. Endoscopic internal drain- This study is in accordance with the ethical standards as laid down in the
1964 Declaration of Helsinki and its later amendments or comparable
age allowed early drain removal and promoted partial
ethical standards.
healing of the abscess cavity.
Conflict of Interest The authors declare that they have no conflict of
Informed Consent Informed consent was obtained from all individual
participants included in the study.
Nonetheless endoscopic treatment, perigastric collection and a
gastro-jejunal fistula were highlighted at contrast medium
opacification. Gastro-jejunal fistula formation was most prob-
ably related to persistent perigastric collection and on-going
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