Obesity Surgery (2018) 28:1456–1457

https://doi.org/10.1007/s11695-018-3193-0

VIDEO SUBMISSION

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

Abstract
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

Introduction

Laparoscopic sleeve gastrectomy (LSG) is the most frequent

Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11695-018-3193-0) 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
donatelligianfranco@gmail.com 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
1
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
2
IRCAD/IHU-Institute of Image-Guided Surgery, 1 Place de by endoscopic procedure often requiring revisional surgery.
l’Hopital, 67000 Strasbourg, France
3
Digestive Endoscopy and Gastroenterology Unit, A.O. Istituti
Ospitalieri di Cremona, Cremona, Italy
4
Department of General and Visceral Surgery, Bichat-Claude Bernard Material and Methods
University Hospital, Paris, France
5
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-
6
Paris-Saclay University, F-91405 Orsay, France operative day 4, dehiscence of proximal staple line was
7
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
fistula sealing was achieved. After 6 months, the patient de-
veloped diffuse peritonitis and sepsis requiring hospital ad-
mission. At a local hospital, there was no availability of inter-
ventional radiology; therefore, surgical procedure was per-
formed. At laparotomy, chronic gastric leak with concomitant
infected abscess was highlighted, and a surgical drainage was
deployed close to staple line.
Three days from surgery, endoscopic internal drain-
age (EID) with insertion of double-pigtail stents across
the leak was performed [4]. Endoscopic internal drain-
age allowed early drain removal and promoted partial
healing of the abscess cavity.
Results
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
infection. Septotomy [5] was then considered as a viable op-
tion. However, it was discarded due to septum thickness and
its marked distance from the pseudo-cavity. Total gastrectomy
and fistulo-jejunal anastomosis were both proposed to the pa-
tient. However, he strongly refused any surgical procedure.
Therefore, it was decided to bypass the fistula with a fully
covered SEMS in order to achieve an endoscopic fistulo-
jejunal anastomosis. A fully covered 80 × 10-mm stent was
delivered. A clip was used to fix the stent to the gastric wall
to prevent migration. At 2-month follow-up, the patient is
asymptomatic on a normal diet with no signs of on-going
inflammation and no weight regain. Stent removal is sched-
uled within 3 months in order to allow complete organization
of the gastro-jejunal fistula exclusion of perigastric collection.
Conclusions
Surgery appears to be the best option for chronic fistula after
laparoscopic sleeve gastrectomy [6]. Surgical fistula-
1457
jejunostomy has been proposed as an effective and less inva-
sive option compared to total gastrectomy [7]. Endoscopic
fistula-jejunostomy by by-passing the fistula with insertion
of fully covered SEMS, as we show in this case, could be
considered a viable option in well selected patients especially
when other endoscopic treatments fail or surgery is refused.
Compliance with Ethical Standards
This study is in accordance with the ethical standards as laid down in the
1964 Declaration of Helsinki and its later amendments or comparable
ethical standards.
Conflict of Interest The authors declare that they have no conflict of
interest.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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