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DOI: 10.1055/a-0631-8479
Endoscopic ultrasound-guided detection and internal drainage of a closed gastro-cutaneous fistula after bariatric surgery
Publication History
Publication Date:
19 June 2018 (online)
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Endoscopic drainage of fistulas with plastic stents after bariatric surgery is a minimally invasive technique with high success and low morbidity rates [1] [2]. However, it is sometimes difficult to find or cannulate the internal orifice of the fistula owing to limited maneuverability, a relatively small opening, tortuous trajectory or even spontaneous closure of the orifice. In such cases, endoscopic ultrasound (EUS)-guided puncture can be an option for draining various fluid collections in the abdominal cavity [3] [4], by finding the internal orifice or by creating an additional trajectory to the collection [5].
We report the case of a 38-year-old patient with a postbariatric gastro-cutaneous fistula who was referred to our department for endoscopic drainage. Despite conservative therapy 3 months after a sleeve gastrectomy, the patient experienced continuous purulent cutaneous discharge of a peri-gastric collection. Water-soluble contrast swallow computed tomography (CT) scan showed a gastro-cutaneous fistula originating at the upper part of the staple line of the sleeve gastrectomy ([Fig. 1 a]).
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During the first endoscopy attempt, the gastric orifice was not visible despite injection of contrast via the cutaneous orifice. A second endoscopy was attempted and the fistula tract was detected endosonographically by injecting solution into the fistula through the cutaneous orifice. A 19-gauge needle was used to puncture the fistula tract and place a guidewire ([Fig. 1 c, d]). Balloon dilation was performed to enlarge the entrance, and a second guidewire was placed. Consequently, two 7-Fr double-pigtail plastic drains were placed in the fistula tract ([Fig. 1 b], [Video 1]).
Video 1 Endoscopic ultrasound-guided drainage of a closed fistula after bariatric surgery.
Quality:
One week after the intervention, there was no purulent cutaneous discharge and the CT scan showed the stents in the fistula through the internal orifice, with no contrast extravasation; the fluid collection had decreased compared with previous imaging ([Fig. 1 e]).
When the fistula orifice is not clearly visible or when it closes spontaneously, EUS procedures allow success in draining the fistula in a one-step procedure.
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References
- 1 Lorenzo D, Guilbaud T, Gonzalez JM. et al. Endoscopic treatment of fistulas after sleeve gastrectomy: a comparison of internal drainage versus closure. Gastrointest Endosc 2018; 87: 429-437
- 2 Bège T, Emungania O, Vitton V. et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc 2011; 73: 238-244
- 3 Souto-Rodríguez R, Alvarez-Sánchez M-V. Endoluminal solutions to bariatric surgery complications: a review with a focus on technical aspects and results. World J Gastrointest Endosc 2017; 9: 105-126
- 4 Alali A, Mosko J, May G. et al. Endoscopic ultrasound-guided management of pancreatic fluid collections: update and review of the literature. Clin Endosc 2017; 50: 117-125
- 5 Bouchard S, Eisendrath P, Toussaint E. et al. Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract. Endoscopy 2016; 48: 809-816