Reply to Rebibo et al.

We have read with great interest the comments of Rebibo et al. and we are grateful for the opportunity to reply to these remarks with some supplementary data.

Our study “Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study” [1] is the largest series published to date examining the management of fistulas due to staple line leak following laparoscopic sleeve gastrectomy (LSG).

We retrospectively gathered data from several centers concerning the treatment of fistulas by interventional endoscopic procedures. We identified several predictive factors associated with faster healing of fistulas: no past history of gastric banding (P = 0.04); small fistula (≤ 1 cm) (P = 0.01); a short time interval between LSG and fistula (≤ 3 days; P = 0.01); and a short time interval (less than 21 days) between diagnosis of the fistula and first endoscopy (P = 0.007). In our series, the efficacy of endoscopic treatment was found to be optimal in the first 6 months of management. Subsequently, surgical treatment should be considered, as the probability of healing following endoscopic treatment decreases.

In our series, we distinguished three types of fistula healing: “spontaneous” healing through medical treatment alone; healing following medical and endoscopic treatment; and healing following radical surgical treatment (conversion to by-pass, or fistulojejunal anastomosis with the jejunum being brought up to the fistulous opening). In all centers, patients were given medical preoperative and postoperative care adapted to their particular situation. Patients who healed spontaneously had been given this type of medical treatment alone. This treatment included broad-spectrum antibiotics, analgesics, antiemetics, antisecretory medications (proton pump inhibitors [PPIs]), etc. All these data were gathered during visits to each of the different centers; however statistical analysis was not performed because of the heterogeneous nature of the data. None of the patients included were treated by octreotide. To our knowledge, there are no published data supporting the use of octreotide for the treatment of post sleeve gastrectomy fistulas.

In our series, 3 out of 4 patients (83 out of 110) underwent early repeat surgery, but no patient achieved healing by direct suture of the staple line leak. In our experience, suture of the fistula orifice is often difficult because of its superior and posterior position on the gastric sleeve. This area is often fragile because of local inflammation and infection which weaken the tissue. Likewise, the results of application of surgical glue or patches of bovine pericardium are disappointing for this indication [2]. However, early repeat surgery allows for irrigation and drainage of intra-abdominal collections, which is an essential part of the management of these patients.

The use of self-expanding metal stents (SEMSs) was the most frequently employed technique in our series. Our study covers a long period (6 years), from August 1 2007 to May 31 2013, and common practices have evolved since then. As demonstrated by our study, metallic stents can lead to a certain number of serious complications (migration, impaction, incarceration, ulcers, and perforation), and therefore their use in this situation continues to decrease. Internal drainage using double-pigtail catheters (DPC) is now the preferred treatment, as described in a recent series [3] [4]. Nonetheless, our algorithm does not exclude the use of stents, although their use remains limited to the treatment of large orifices.

We would like to comment on the statements concerning gastric stenosis. The occurrence of stenosis following sleeve gastrectomy is a complication which should be extremely rare, as sleeve gastrectomy is currently a standardized surgery in which tools are used to calibrate the gastric sleeve. The occurrence of a stenosis should not be confused with the occurrence of a twist of the gastric sleeve. The latter is a more frequent complication, defined by the clockwise rotation of the gastric sleeve, leading to a functional stenosis. Twists are difficult to treat endoluminally, as possible mechanical endoscopic treatments (such as hydropneumatic dilation or stent placement) have only a temporary untwisting effect. When dilation is discontinued or when a stent is removed, the gastric sleeve tends to re-twist. In our series, 6 patients had a twist of the gastric sleeve, and none of the endoscopic treatments implemented (balloon dilation, SEMS, DPC) allowed healing of the fistula or resolution of the twist. All 6 patients underwent repeat surgery, which was either gastric by-pass or fistulojejunal anastomosis (data not shown). Additionally, one patient not included in this series, whose twist was treated by stent placement at another center, presented considerable morbidity due to the stent, which was complicated by a triple digestive perforation, of the esophagus (leading to pyomediastinum and pneumomediastinum), of the gastric sleeve, and of the gastric antrum due to impaction.

Concerning over-the-scope clips (OTSCs), as shown by Surace et al. [5] and Mercky et al. [6],we believe that OTSCs can help in the closing of small fistulas presenting with little or no inflammation. This is indeed often the case after an initial treatment, such as effective drainage of a collection by a DPC.

This is what is presented in our algorithm. Although it has been criticized for being too simple, we believe that it is comprehensible, coherent, and an accurate portrayal of common practices for the management of fistulas at our center.

In conclusion, as stated in our original article, the management of post sleeve gastrectomy fistula is a complex, long, and difficult process. Interventional endoscopy can allow healing of the fistula in many cases. We are convinced that the management of this complication necessitates close cooperation between several different specialties: the interventional endoscopist, the radiologist, the anesthetist/intensive care specialist, and the surgeon, either at the acute phase for drainage of the fistula, or following failure of endoscopic treatment, after which gastric by-pass or fistulojejunal anastomosis is performed.

• References

• 1 Christophorou D, Valats JC, Funakoshi N et al. Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study. Endoscopy 2015; 47: 988-996
• 2 Consten ECJ, Gagner M, Pomp A et al. Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg 2004; 14: 1360-1366
• 3 Donatelli G, Dumont JL, Cereati F et al. Treatment of leaks following sleeve gastrectomy by endoscopic internal drainage (EID). Obes Surg 2015; 25: 1293-1301
• 4 Donatelli G, Catheline JM, Dumont JL et al. Outcome of leaks after sleeve gastrectomy based on a new algorithm addressing leak size and gastric stenosis. Obes Surg 2015; 25: 1258-1260
• 5 Surace M, Mercky P, Demarquay JF et al. Endoscopic management of GI fistulae with the over-the-scope clip system (with video). Gastrointest Endosc 2011; 74: 1416-1419
• 6 Mercky P, Gonzalez JM, Aimore Bonin E et al. Usefulness of over-the-scope clipping system for closing digestive fistulas. Dig Endosc 2015; 27: 18-24