Endoscopic septotomy for fistula after bariatric surgery

Abstract

Endoscopic septotomy for fistula after bariatric surgery Gastric fistula following bariatric surgery is a complication with considerable morbidity and mortality After Rouxen-Y gastric bypass (RYGB), the gastric pouch may develop a chronic fistula and the formation of a perigastric cavity bounded by a septum. The altered anatomy chronically elevates the intraluminal pressure, impairing emptying of the perigastric cavity and perpetuating the fistula [3]. Endoscopic septotomy is a minimally invasive technique for cutting the septum. The goals are ensuring adequate patency of the perigastric cavity, decreasing its pressure, and draining the fistula A 67-year-old woman underwent a RYGB (body mass index: 48 kg/m before, 25 kg/m after). She developed a gastrocutaneous fistula, which was unsuccessfully treated with a long-term nasoenteric tube. Eight months after RYGB, she was referred for endoscopic assessment ( Video 1). Sutures were identified in the greater curvature of the gastric pouch. They were removed with endoscopic scissors and a perigastric cavity (bounded by a septum) with a fistula orifice in it was identified. The fistula orifice was initially treated with argon plasma coagulation and a guidewire was externalized through the fistula's cutaneous orifice ( Fig. After 3 months, the gastrocutaneous leak was reduced but not resolved. We removed the pigtail, performed a septotomy with an IT knife, and placed an esophageal fully covered (28 160 mm) self-expandable metal stent. The proximal end of the stent was fixed by endosuture to avoid migration. After 1 week, the stent was removed and the patient was able to take a soft diet. Four weeks later, the cutaneous fistula orifice was closed ( Fig. At 3 weeks' follow-up, the patient was asymptomatic and doing well on a regular diet.

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