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Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach
CASE STUDY
Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach Benjamin F. Merrifield, MD, David Lautz, MD, Christopher C. Thompson, MD, MHES Boston, Massachusetts, USA
Background: Gastric leaks represent an important source of morbidity and mortality associated with Roux-en-Y gastric bypass. These leaks, once managed acutely, can become chronic and represent a difficult clinical challenge. Surgical options to address a chronic gastric leak are technically challenging and often unsuccessful. We present a novel peroral endoscopic treatment for patients with chronic gastric leaks after Roux-en-Y gastric bypass. Design: Case series. Interventions: Repair of chronic gastric leaks after Roux-en-Y gastric bypass by using a combination of argon plasma coagulation, hemoclips, fibrin glue, Polyflex stent placement, and distal gastrojejunal stenosis dilation. The goal was to achieve durable fistula closure and avoid surgery. Main Outcome Measurements: Durable fistula closure as assessed by an upper-GI series and clinical evaluation. Results: Gastric leak closure was achieved in all 3 patients, with complete resolution of symptoms. Polyflex stent migration into the Roux limb occurred in 1 patient, and this was retrieved endoscopically. There were no other significant complications. Conclusions: Peroral endoscopic repair of gastric leaks is technically feasible. This procedure may offer a less invasive alternative to traditional surgical revision.
Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure in the United States today. Gastric staple line leak is a well-described complication of this procedure, which can result in peritonitis, abscess formation, sepsis, and death. The standard treatment of a gastric leak in the acute setting is treatment of the sepsis with fluid resuscitation, broad-spectrum intravenous (IV) antibiotics, and adequate drainage of the leak. This can be accomplished in some cases with percutaneous approaches, but, in many cases, operative intervention with large-drain placement and/or surgical repair is necessary. After successful acute management, some patients develop persistent leaks that fail to completely heal with conservative management. These patients offer a significant clinical dilemma for the surgeon. Conservative measures may offer nothing, but surgical intervention can be technically challenging. Primary surgical repair of the
leak often fails, and surgical resection of the pouch is not an attractive option. This series highlights novel endoscopic approaches to repairing chronic gastric leaks. These patients had been hospitalized for prolonged periods of time after successful acute management and had been sent to our center because of chronic leaks in the hope of avoiding surgery.
PATIENTS AND METHODS Case 1
Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2005.11.018
A 48-year-old woman underwent vertical banded gastroplasty 9 years previously in Israel. This was complicated by gastric staple-line dehiscence with gastrogastric fistula, severe GERD, and weight regain. She recently underwent a revision, with conversion to a divided Roux-en-Y gastric bypass. Extensive adhesions were noted during the revision. Ten days after the operation, she developed worsening abdominal pain and sepsis. A CT revealed 2 intraabdominal abscesses, and a Gastrografin (Bristol-Myers
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Squibb, Princeton, NJ) swallow demonstrated a leak from the proximal gastric pouch to the peritoneum. The patient was treated with IV antibiotics and percutaneous drainage. One week later, she experienced a low-grade temperature and nausea. A CT showed a persistent fluid collection between the pouch and the excluded stomach, and a leak from the proximal pouch. Two additional percutaneous drains were then placed into the fluid collection. In addition, a G tube was placed into the defunctionalized stomach. After a prolonged hospitalization, she was transferred to our institution for possible endoscopic therapy. On upper endoscopy, 2 holes were visible just above the Z-line. The distal tip of the surgical drain could be seen though the larger hole, which measured 4 mm in diameter. The lower esophageal sphincter (LES) appeared stenotic, and the gastroscope was passed through it with resistance. The pouch mucosa and gastrojejunal anastomosis appeared normal, at 45 cm. One TriClip (Cook Endoscopy, Wilson-Cook, Winston-Salem, NC) and 3 Quick Clips (Olympus America Inc, Melville, NY) were successfully used to close the larger fistula. A fourth Quick Clip was used to close the smaller defect. Contrast material injected into the esophagus did not extravasate into the peritoneum by fluoroscopy. There were no complications associated with the procedure. Twenty days later, the patient returned for an outpatient upper endoscopy after experiencing abdominal pain; an upper-GI series revealed recurrent gastroperitoneal and gastrogastric fistulas. On repeat endoscopy, the patient was found to have a persistent stenosis and recurrence of the larger fistula. The stricture, just below the Z-line, was dilated with a CRE balloon (Boston Scientific, Natick, Mass) to 12 mm. The larger fistula was again noted just proximal to the area of stenosis. Only the TriClip remained in place. Argon plasma coagulation was applied to the mucosa surrounding the rim of the fistula in an attempt to ablate the mucosa, which is thought to promote fusion of apposed tissue. Two additional TriClips were then used to close the defect. The gastrogastric fistula was not endoscopically visible and was not addressed. There were no complications associated with the procedure, and the patient’s symptoms resolved. Six weeks later, she returned for a surveillance upper endoscopy. The previously placed clips were seen, and the peritoneal fistula appeared closed and healed. The gastrogastric fistula was again not endoscopically visible. The LES was patent but was narrowed to approximately 8 mm in diameter. The stricture was dilated sequentially to 15 mm by using a CRE balloon dilator. There were no complications. A subsequent barium swallow again demonstrated closure of the gastroperitoneal fistula and showed a small persistent gastrogastric fistula. The gastrogastric fistula was treated conservatively with proton pump inhibitors. All external drains were removed, and the patient did well at 1-year follow-up. www.giejournal.org
Endoscopic repair of gastric leaks
Figure 1. Gastroperitoneal fistula with external drain tip visible through defect.
Case 2 A 35-year-old morbidly obese man underwent Roux-en-Y gastric bypass that was complicated by cholecystitis, gastroperitoneal fistula, and a perigastric abscess. The patient returned to the operating room for a cholecystectomy and placement of a Jackson-Pratt (JP) drain into the perigastric abscess. Despite this, the patient continued to experience pain, fevers, and passage of food into his JP drain reservoir. An upper-GI series confirmed a gastroperitoneal leak and a gastrogastric fistula. He was initially treated conservatively with drainage, total parenteral nutrition (TPN), and broad-spectrum antibiotics. After a 2-month hospitalization, the patient wished to avoid a proposed third surgery and was transferred to our institution for possible endoscopic fistula closure. On upper endoscopy, a 5 7-mm hole was seen just below the Z-line through which the JP drain could be visualized (Fig. 1). Immediately distal to the defect, the proximal pouch was stenotic, and the endoscope passed with resistance. In addition, the gastrojejunal anastomosis was strictured to a diameter of 5 mm. This was dilated to 1 cm with a CRE balloon. Starting with the distal edge of the peritoneal fistula and working proximally, the defect was closed with 2 Resolution Clips (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass). After the defect was closed, 2 mL of Tisseel fibrin glue (Baxter, Deerfield, Ill) was topically applied over the site. There were no immediate complications, and the patient tolerated the procedure well. One day after the procedure, it was noted that fluid rapidly entered the JP drain after the patient drank liquid. On repeat upper endoscopy, both endoclips and fibrin glue remained in place. The endoclips were removed, but the gastroperitoneal fistula could not be seen. Because of its proximity to the gastroperitoneal fistula, the JP drain was withdrawn 5 cm, with significant resistance, under fluoroscopic guidance. Subsequently, the gastrogastric fistula was identified. The gastroscope was advanced through the 9-mm diameter opening into the defunctionalized stomach. No peritoneal fistula was seen Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 711
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Figure 2. Polyflex stent covering defect.
Figure 3. Resolution of leak after Polyflex removal.
from the defunctionalized stomach. The Bard EndoCinch device (CR Bard Inc, Murray Hill, NJ) was used to close the gastrogastric fistula with 4 sutures, and 2 Resolution Clips were placed to reinforce the closure. Five mL of Tisseel fibrin glue was then applied through a catheter onto the repair site. Finally, a 16/20 90-mm Polyflex stent (Boston Scientific) was placed into the esophagus, covering the area of the fistula and traversing both areas of stenosis in the proximal pouch and the gastrojejunal anastomosis. The patient tolerated the procedure well and the JP drainage ceased. Within 24 hours, the patient felt well and tolerated oral feeding. The patient continued to do well, and, 1 month later, the stent was removed by using a double-channel endoscope and 2 rat-tooth forceps. The gastroperitoneal fistula repair site appeared healed. The previously seen gastrogastric fistula was significantly smaller in diameter. The gastrojejunal anastomosis appeared normal, without ulceration, bleeding, or stenosis. A CRE balloon was inflated to 18 mm in the esophagus, and contrast mixed with methylene blue was injected. There was no evidence of fluid extravasation, and no methylene blue entered the JP drain. A Gastrografin swallow demonstrated no evidence of peritoneal leak. The drain was gradually removed and the gastrogastric fistula was treated conservatively with proton pump inhibitors. Five months after stent removal, the patient continued to do well, was on a regular diet, and had no abdominal pain.
A 45-year-old woman had a divided Roux-en-Y gastric bypass with cholecystectomy for morbid obesity, which was complicated by a postoperative gastrojejunal leak. The patient returned to the operating room for surgical
repair and tube gastrostomy. Despite this, the patient had a persistent leak at the gastrojejunal anastomosis. In addition, she had radiologic evidence of a gastropleural fistula and a gastrogastric fistula. She remained symptomatic, with dysphagia and frequent abdominal pain, and was transferred to our institution for further management. Upper endoscopy revealed marked stenosis just below the Z-line, which did not allow passage of a standard gastroscope. A gastroperitoneal fistula was also noted at this site. The stenosis was dilated with a CRE balloon from 8 to 14 mm. The gastric pouch appeared normal. There was no endoscopic evidence of the gastrogastric fistula. The gastrojejunal anastomosis appeared mildly stenosed but allowed easy passage of the gastroscope into the jejunum, which appeared normal. Two 18 60 Polyflex stents were placed to cover the distal esophagus, the stricture, the fistula, and the pouch. In recovery, the patient developed epigastric pain. The following day, her pain persisted and an upper-GI series showed that the gastroperitoneal fistula was still filling with contrast and communicated with the bronchial tree. A second EGD was then performed. The 2 Polyflex stents were seen in the esophagus, just above the stenosis at the gastroesophageal junction. These were removed by using a rat-tooth forceps. The fistulous opening at the Z-line appeared to split into 2 smaller openings (3 mm and 5 mm) just beyond its lumen. An ultrathin endoscope was advance through the 5-mm opening into a 3 5-cm loculated area within the pleural space. Two small (2 mm) bronchial openings were seen within this cavity. The loculated cavity was filled with 7 mL Tisseel fibrin glue, and the remainder of the fistula was then completely sealed up to its lumen at the gastroesophageal junction. An 18 120-mm Polyflex stent was placed into the esophagus, covering the fistula (Fig. 2). A repeat upper-GI series showed no evidence of the fistula.
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Case 3
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The patient tolerated the procedure well and was able to tolerate an oral diet the next day. Six weeks later, the patient developed a partial smallbowel obstruction caused by migration of the Polyflex stent (Fig. 3). An EGD showed that the gastropleuralbronchial fistula was closed, and a pinpoint gastrogastric fistula was seen. The Polyflex stent was found 70 cm from the gums, in the jejunum. The stent was removed endoscopically by using a rat-tooth forceps. The patient tolerated the procedure well and continued to do well at 2 months. An upper-GI series showed a small gastrogastric fistula but did not reveal any signs of the peritoneal leak.
DISCUSSION Gastric pouch leaks after RYGB are a known complication, with significant morbidity and mortality. Reported rates of anastomotic leaks after RYGB range from 0% to 5.6%.1,2 As noted by Gonzalez et al,3 the true incidence of gastric pouch leaks is obscured by the tendency of investigators to report leaking gastrojejunostomies together with gastric leaks under the general term ‘‘anastomotic leak.’’ Some of these leaks can be managed nonoperatively in the acute setting, and others require urgent exploration. Despite aggressive medical and/or surgical management, some patients will develop ongoing sepsis, multisystem organ failure, and death. Of those who survive the initial sepsis, some develop persistent leaks, despite adequate drainage of associated fluid collections. Surgical options for treating chronic gastric leaks are technically challenging because of altered anatomy, chronic inflammation, and adhesions, and are associated with significant operative risk. While there are no reports of endoscopic gastric leak repair after RYGB, there are analogous reports of esophageal fistula repair. Endoclips have previously been used to close both acute esophageal perforations and chronic esophageal fistulas that have failed to close with conservative management (eg, intravenous antibiotics, chest-tube drainage, and total parenteral nutrition).4-6 In addition to clips, there are also reports of endoscopically placed fibrin glue to close an enteric fistula.7-10 Animal studies have indicated that mucosal ablation before tissue apposition leads to a more durable closure.11 In this series, we used mucosal ablation based on our clinical experience with gastrogastric fistula closure after RYGB in which excoriation of the opposing mucosal surfaces before suturing seemed to promote tissue healing. In addition to clips, glue, and argon plasma coagulation, self-expanding covered metal stents have been used to close esophageal leaks and perforations.12-15 These devices act as a fluid barrier and may promote re-epithelization. Stent migration and tissue overgrowth are potential complications, and stent removal can be challenging. The Polyflex stent is a plastic, removable stent www.giejournal.org
Endoscopic repair of gastric leaks
that may reduce tissue overgrowth and the risks associated with stent removal.14 In 2 cases, the stent was placed across an area of stenosis, thus lessening the possibility of stent migration. Despite this, 1 stent migrated into the Roux limb, and endoscopic removal was challenging. In leaks without accompanying stenosis, the risk of migration is even higher. Stents designed specifically for this condition may resist migration and prove helpful in the future. While the impact of stenosis on the formation of a fistula has not been established, we believe that dilating stenotic areas that lie just distal to a fistula is well tolerated and may be an important adjunct in preventing recurrence of the leak. In addition, dilation facilitates stent placement, which may form a more durable barrier and allow patients to quickly tolerate a regular diet. This report suggests that chronic gastric leaks after RYGB can be successfully closed by using endoscopic methods. We used a combination of techniques, involving denuding mucosa, clip placement, gluing, luminal stent placement, and stenosis dilation. This method of repair may require several endoscopic examinations, but the leaks were ultimately closed, and surgery was avoided. The procedures were well tolerated, with minimal complications. After the repair, all 3 patients were able to advance their diet quickly and left the hospital within a few days, sometimes after months of being hospitalized. On long-term follow-up, there have been no recurrence of the leaks. In cases like those reported above, patient selection is vital and close communication with the patient’s surgeon is essential. We emphasize that this procedure was not performed (and may not be appropriate) in the acute setting. Provided patients are clinically stable and closely followed in conjunction with a surgical team, endoscopic repair of chronic gastric leaks after RYGB may be a safe and effective option for patients who would otherwise undergo complex surgical revision.
REFERENCES 1. Higda KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patientsdWhat have we learned? Obes Surg 2000;10:509-13. 2. Fernandez AZ Jr, DeMaria EJ, Tichansky DS. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc 2004;18: 193-7. 3. Gonzalez R, Nelson LG, Gallagher SF, et al. Anastomotic leaks after laparoscopic gastric bypass. Obes Surg 2004;14:1299-307. 4. Abe N, Sugiyama M, Hashimoto Y, et al. Endoscopic nasomediastinal drainage followed by clip application for treatment of delayed esophageal perforation with mediastinitis. Gastrointest Endosc 2001;54: 646-8. 5. Raymer GS, Sadana A, Campbell DB, et al. Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae. Clin Gastroenterol Hepatol 2003;1:44-50.
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6. Cipolletta L, Bianco MA, Rotondano G, Marmo R, Piscopo R, Meucci C. Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures. Endoscopy 2000;32:720-2. 7. Rabago LR, Ventosa N, Castro JL, et al. Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue. Endoscopy 2002;34:632-8. 8. Petersen B, Barkun A, Carpenter S, et al. Tissue adhesives and fibrin glues: November 2003. Gastrointest Endosc 2004;60:327-33. 9. Maluf-Filho F, Moura E, Sakai P, et al. Endoscopic treatment of esophagogastric fistulae with an acellular matrix [abstract]. Gastrointest Endosc 2004;59:AB151. 10. Scappaticci E, Ardissone F, Baldi S, et al. Closure of an iatrogenic tracheo-esophageal fistula with bronchoscopic gluing in a mechanically ventilated adult patient. Ann Thorac Surg 2004;77:328-9. 11. Felsher J, Farres H, Chand B, et al. Mucosal apposition in endoscopic suturing. Gastrointest Endosc 2003;58:867-70. 12. Adam A, Watkinson AF, Dussek J. Boerhaave syndrome: to treat or not to treat by means of insertion of a metallic stent. J Vasc Interv Radiol 1995;6:741-3; discussion 744-6.
13. Roy-Choudhury SH, Nicholson AA, Wedgwood KR, et al. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents. AJR Am J Roentgenol 2001;176: 161-5. 14. Siersema PD, Homs MY, Haringsma J, et al. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 2003;58:356-61. 15. Gelbmann CM, Ratiu NL, Rath HC, et al. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy 2004;36:695-9.
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Current affiliations: Division of Gastroenterology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA. Reprint requests: Christopher C. Thompson, MD, Division of Gastroenterology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115.
Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach Benjamin F. Merrifield, MD, David Lautz, MD, Christopher C. Thompson, MD, MHES Boston, Massachusetts, USA
Background: Gastric leaks represent an important source of morbidity and mortality associated with Roux-en-Y gastric bypass. These leaks, once managed acutely, can become chronic and represent a difficult clinical challenge. Surgical options to address a chronic gastric leak are technically challenging and often unsuccessful. We present a novel peroral endoscopic treatment for patients with chronic gastric leaks after Roux-en-Y gastric bypass. Design: Case series. Interventions: Repair of chronic gastric leaks after Roux-en-Y gastric bypass by using a combination of argon plasma coagulation, hemoclips, fibrin glue, Polyflex stent placement, and distal gastrojejunal stenosis dilation. The goal was to achieve durable fistula closure and avoid surgery. Main Outcome Measurements: Durable fistula closure as assessed by an upper-GI series and clinical evaluation. Results: Gastric leak closure was achieved in all 3 patients, with complete resolution of symptoms. Polyflex stent migration into the Roux limb occurred in 1 patient, and this was retrieved endoscopically. There were no other significant complications. Conclusions: Peroral endoscopic repair of gastric leaks is technically feasible. This procedure may offer a less invasive alternative to traditional surgical revision.
Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure in the United States today. Gastric staple line leak is a well-described complication of this procedure, which can result in peritonitis, abscess formation, sepsis, and death. The standard treatment of a gastric leak in the acute setting is treatment of the sepsis with fluid resuscitation, broad-spectrum intravenous (IV) antibiotics, and adequate drainage of the leak. This can be accomplished in some cases with percutaneous approaches, but, in many cases, operative intervention with large-drain placement and/or surgical repair is necessary. After successful acute management, some patients develop persistent leaks that fail to completely heal with conservative management. These patients offer a significant clinical dilemma for the surgeon. Conservative measures may offer nothing, but surgical intervention can be technically challenging. Primary surgical repair of the
leak often fails, and surgical resection of the pouch is not an attractive option. This series highlights novel endoscopic approaches to repairing chronic gastric leaks. These patients had been hospitalized for prolonged periods of time after successful acute management and had been sent to our center because of chronic leaks in the hope of avoiding surgery.
PATIENTS AND METHODS Case 1
Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2005.11.018
A 48-year-old woman underwent vertical banded gastroplasty 9 years previously in Israel. This was complicated by gastric staple-line dehiscence with gastrogastric fistula, severe GERD, and weight regain. She recently underwent a revision, with conversion to a divided Roux-en-Y gastric bypass. Extensive adhesions were noted during the revision. Ten days after the operation, she developed worsening abdominal pain and sepsis. A CT revealed 2 intraabdominal abscesses, and a Gastrografin (Bristol-Myers
710 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
Merrifield et al
Squibb, Princeton, NJ) swallow demonstrated a leak from the proximal gastric pouch to the peritoneum. The patient was treated with IV antibiotics and percutaneous drainage. One week later, she experienced a low-grade temperature and nausea. A CT showed a persistent fluid collection between the pouch and the excluded stomach, and a leak from the proximal pouch. Two additional percutaneous drains were then placed into the fluid collection. In addition, a G tube was placed into the defunctionalized stomach. After a prolonged hospitalization, she was transferred to our institution for possible endoscopic therapy. On upper endoscopy, 2 holes were visible just above the Z-line. The distal tip of the surgical drain could be seen though the larger hole, which measured 4 mm in diameter. The lower esophageal sphincter (LES) appeared stenotic, and the gastroscope was passed through it with resistance. The pouch mucosa and gastrojejunal anastomosis appeared normal, at 45 cm. One TriClip (Cook Endoscopy, Wilson-Cook, Winston-Salem, NC) and 3 Quick Clips (Olympus America Inc, Melville, NY) were successfully used to close the larger fistula. A fourth Quick Clip was used to close the smaller defect. Contrast material injected into the esophagus did not extravasate into the peritoneum by fluoroscopy. There were no complications associated with the procedure. Twenty days later, the patient returned for an outpatient upper endoscopy after experiencing abdominal pain; an upper-GI series revealed recurrent gastroperitoneal and gastrogastric fistulas. On repeat endoscopy, the patient was found to have a persistent stenosis and recurrence of the larger fistula. The stricture, just below the Z-line, was dilated with a CRE balloon (Boston Scientific, Natick, Mass) to 12 mm. The larger fistula was again noted just proximal to the area of stenosis. Only the TriClip remained in place. Argon plasma coagulation was applied to the mucosa surrounding the rim of the fistula in an attempt to ablate the mucosa, which is thought to promote fusion of apposed tissue. Two additional TriClips were then used to close the defect. The gastrogastric fistula was not endoscopically visible and was not addressed. There were no complications associated with the procedure, and the patient’s symptoms resolved. Six weeks later, she returned for a surveillance upper endoscopy. The previously placed clips were seen, and the peritoneal fistula appeared closed and healed. The gastrogastric fistula was again not endoscopically visible. The LES was patent but was narrowed to approximately 8 mm in diameter. The stricture was dilated sequentially to 15 mm by using a CRE balloon dilator. There were no complications. A subsequent barium swallow again demonstrated closure of the gastroperitoneal fistula and showed a small persistent gastrogastric fistula. The gastrogastric fistula was treated conservatively with proton pump inhibitors. All external drains were removed, and the patient did well at 1-year follow-up. www.giejournal.org
Endoscopic repair of gastric leaks
Figure 1. Gastroperitoneal fistula with external drain tip visible through defect.
Case 2 A 35-year-old morbidly obese man underwent Roux-en-Y gastric bypass that was complicated by cholecystitis, gastroperitoneal fistula, and a perigastric abscess. The patient returned to the operating room for a cholecystectomy and placement of a Jackson-Pratt (JP) drain into the perigastric abscess. Despite this, the patient continued to experience pain, fevers, and passage of food into his JP drain reservoir. An upper-GI series confirmed a gastroperitoneal leak and a gastrogastric fistula. He was initially treated conservatively with drainage, total parenteral nutrition (TPN), and broad-spectrum antibiotics. After a 2-month hospitalization, the patient wished to avoid a proposed third surgery and was transferred to our institution for possible endoscopic fistula closure. On upper endoscopy, a 5 7-mm hole was seen just below the Z-line through which the JP drain could be visualized (Fig. 1). Immediately distal to the defect, the proximal pouch was stenotic, and the endoscope passed with resistance. In addition, the gastrojejunal anastomosis was strictured to a diameter of 5 mm. This was dilated to 1 cm with a CRE balloon. Starting with the distal edge of the peritoneal fistula and working proximally, the defect was closed with 2 Resolution Clips (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass). After the defect was closed, 2 mL of Tisseel fibrin glue (Baxter, Deerfield, Ill) was topically applied over the site. There were no immediate complications, and the patient tolerated the procedure well. One day after the procedure, it was noted that fluid rapidly entered the JP drain after the patient drank liquid. On repeat upper endoscopy, both endoclips and fibrin glue remained in place. The endoclips were removed, but the gastroperitoneal fistula could not be seen. Because of its proximity to the gastroperitoneal fistula, the JP drain was withdrawn 5 cm, with significant resistance, under fluoroscopic guidance. Subsequently, the gastrogastric fistula was identified. The gastroscope was advanced through the 9-mm diameter opening into the defunctionalized stomach. No peritoneal fistula was seen Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 711
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Figure 2. Polyflex stent covering defect.
Figure 3. Resolution of leak after Polyflex removal.
from the defunctionalized stomach. The Bard EndoCinch device (CR Bard Inc, Murray Hill, NJ) was used to close the gastrogastric fistula with 4 sutures, and 2 Resolution Clips were placed to reinforce the closure. Five mL of Tisseel fibrin glue was then applied through a catheter onto the repair site. Finally, a 16/20 90-mm Polyflex stent (Boston Scientific) was placed into the esophagus, covering the area of the fistula and traversing both areas of stenosis in the proximal pouch and the gastrojejunal anastomosis. The patient tolerated the procedure well and the JP drainage ceased. Within 24 hours, the patient felt well and tolerated oral feeding. The patient continued to do well, and, 1 month later, the stent was removed by using a double-channel endoscope and 2 rat-tooth forceps. The gastroperitoneal fistula repair site appeared healed. The previously seen gastrogastric fistula was significantly smaller in diameter. The gastrojejunal anastomosis appeared normal, without ulceration, bleeding, or stenosis. A CRE balloon was inflated to 18 mm in the esophagus, and contrast mixed with methylene blue was injected. There was no evidence of fluid extravasation, and no methylene blue entered the JP drain. A Gastrografin swallow demonstrated no evidence of peritoneal leak. The drain was gradually removed and the gastrogastric fistula was treated conservatively with proton pump inhibitors. Five months after stent removal, the patient continued to do well, was on a regular diet, and had no abdominal pain.
A 45-year-old woman had a divided Roux-en-Y gastric bypass with cholecystectomy for morbid obesity, which was complicated by a postoperative gastrojejunal leak. The patient returned to the operating room for surgical
repair and tube gastrostomy. Despite this, the patient had a persistent leak at the gastrojejunal anastomosis. In addition, she had radiologic evidence of a gastropleural fistula and a gastrogastric fistula. She remained symptomatic, with dysphagia and frequent abdominal pain, and was transferred to our institution for further management. Upper endoscopy revealed marked stenosis just below the Z-line, which did not allow passage of a standard gastroscope. A gastroperitoneal fistula was also noted at this site. The stenosis was dilated with a CRE balloon from 8 to 14 mm. The gastric pouch appeared normal. There was no endoscopic evidence of the gastrogastric fistula. The gastrojejunal anastomosis appeared mildly stenosed but allowed easy passage of the gastroscope into the jejunum, which appeared normal. Two 18 60 Polyflex stents were placed to cover the distal esophagus, the stricture, the fistula, and the pouch. In recovery, the patient developed epigastric pain. The following day, her pain persisted and an upper-GI series showed that the gastroperitoneal fistula was still filling with contrast and communicated with the bronchial tree. A second EGD was then performed. The 2 Polyflex stents were seen in the esophagus, just above the stenosis at the gastroesophageal junction. These were removed by using a rat-tooth forceps. The fistulous opening at the Z-line appeared to split into 2 smaller openings (3 mm and 5 mm) just beyond its lumen. An ultrathin endoscope was advance through the 5-mm opening into a 3 5-cm loculated area within the pleural space. Two small (2 mm) bronchial openings were seen within this cavity. The loculated cavity was filled with 7 mL Tisseel fibrin glue, and the remainder of the fistula was then completely sealed up to its lumen at the gastroesophageal junction. An 18 120-mm Polyflex stent was placed into the esophagus, covering the fistula (Fig. 2). A repeat upper-GI series showed no evidence of the fistula.
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Case 3
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The patient tolerated the procedure well and was able to tolerate an oral diet the next day. Six weeks later, the patient developed a partial smallbowel obstruction caused by migration of the Polyflex stent (Fig. 3). An EGD showed that the gastropleuralbronchial fistula was closed, and a pinpoint gastrogastric fistula was seen. The Polyflex stent was found 70 cm from the gums, in the jejunum. The stent was removed endoscopically by using a rat-tooth forceps. The patient tolerated the procedure well and continued to do well at 2 months. An upper-GI series showed a small gastrogastric fistula but did not reveal any signs of the peritoneal leak.
DISCUSSION Gastric pouch leaks after RYGB are a known complication, with significant morbidity and mortality. Reported rates of anastomotic leaks after RYGB range from 0% to 5.6%.1,2 As noted by Gonzalez et al,3 the true incidence of gastric pouch leaks is obscured by the tendency of investigators to report leaking gastrojejunostomies together with gastric leaks under the general term ‘‘anastomotic leak.’’ Some of these leaks can be managed nonoperatively in the acute setting, and others require urgent exploration. Despite aggressive medical and/or surgical management, some patients will develop ongoing sepsis, multisystem organ failure, and death. Of those who survive the initial sepsis, some develop persistent leaks, despite adequate drainage of associated fluid collections. Surgical options for treating chronic gastric leaks are technically challenging because of altered anatomy, chronic inflammation, and adhesions, and are associated with significant operative risk. While there are no reports of endoscopic gastric leak repair after RYGB, there are analogous reports of esophageal fistula repair. Endoclips have previously been used to close both acute esophageal perforations and chronic esophageal fistulas that have failed to close with conservative management (eg, intravenous antibiotics, chest-tube drainage, and total parenteral nutrition).4-6 In addition to clips, there are also reports of endoscopically placed fibrin glue to close an enteric fistula.7-10 Animal studies have indicated that mucosal ablation before tissue apposition leads to a more durable closure.11 In this series, we used mucosal ablation based on our clinical experience with gastrogastric fistula closure after RYGB in which excoriation of the opposing mucosal surfaces before suturing seemed to promote tissue healing. In addition to clips, glue, and argon plasma coagulation, self-expanding covered metal stents have been used to close esophageal leaks and perforations.12-15 These devices act as a fluid barrier and may promote re-epithelization. Stent migration and tissue overgrowth are potential complications, and stent removal can be challenging. The Polyflex stent is a plastic, removable stent www.giejournal.org
Endoscopic repair of gastric leaks
that may reduce tissue overgrowth and the risks associated with stent removal.14 In 2 cases, the stent was placed across an area of stenosis, thus lessening the possibility of stent migration. Despite this, 1 stent migrated into the Roux limb, and endoscopic removal was challenging. In leaks without accompanying stenosis, the risk of migration is even higher. Stents designed specifically for this condition may resist migration and prove helpful in the future. While the impact of stenosis on the formation of a fistula has not been established, we believe that dilating stenotic areas that lie just distal to a fistula is well tolerated and may be an important adjunct in preventing recurrence of the leak. In addition, dilation facilitates stent placement, which may form a more durable barrier and allow patients to quickly tolerate a regular diet. This report suggests that chronic gastric leaks after RYGB can be successfully closed by using endoscopic methods. We used a combination of techniques, involving denuding mucosa, clip placement, gluing, luminal stent placement, and stenosis dilation. This method of repair may require several endoscopic examinations, but the leaks were ultimately closed, and surgery was avoided. The procedures were well tolerated, with minimal complications. After the repair, all 3 patients were able to advance their diet quickly and left the hospital within a few days, sometimes after months of being hospitalized. On long-term follow-up, there have been no recurrence of the leaks. In cases like those reported above, patient selection is vital and close communication with the patient’s surgeon is essential. We emphasize that this procedure was not performed (and may not be appropriate) in the acute setting. Provided patients are clinically stable and closely followed in conjunction with a surgical team, endoscopic repair of chronic gastric leaks after RYGB may be a safe and effective option for patients who would otherwise undergo complex surgical revision.
REFERENCES 1. Higda KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patientsdWhat have we learned? Obes Surg 2000;10:509-13. 2. Fernandez AZ Jr, DeMaria EJ, Tichansky DS. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc 2004;18: 193-7. 3. Gonzalez R, Nelson LG, Gallagher SF, et al. Anastomotic leaks after laparoscopic gastric bypass. Obes Surg 2004;14:1299-307. 4. Abe N, Sugiyama M, Hashimoto Y, et al. Endoscopic nasomediastinal drainage followed by clip application for treatment of delayed esophageal perforation with mediastinitis. Gastrointest Endosc 2001;54: 646-8. 5. Raymer GS, Sadana A, Campbell DB, et al. Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae. Clin Gastroenterol Hepatol 2003;1:44-50.
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6. Cipolletta L, Bianco MA, Rotondano G, Marmo R, Piscopo R, Meucci C. Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures. Endoscopy 2000;32:720-2. 7. Rabago LR, Ventosa N, Castro JL, et al. Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue. Endoscopy 2002;34:632-8. 8. Petersen B, Barkun A, Carpenter S, et al. Tissue adhesives and fibrin glues: November 2003. Gastrointest Endosc 2004;60:327-33. 9. Maluf-Filho F, Moura E, Sakai P, et al. Endoscopic treatment of esophagogastric fistulae with an acellular matrix [abstract]. Gastrointest Endosc 2004;59:AB151. 10. Scappaticci E, Ardissone F, Baldi S, et al. Closure of an iatrogenic tracheo-esophageal fistula with bronchoscopic gluing in a mechanically ventilated adult patient. Ann Thorac Surg 2004;77:328-9. 11. Felsher J, Farres H, Chand B, et al. Mucosal apposition in endoscopic suturing. Gastrointest Endosc 2003;58:867-70. 12. Adam A, Watkinson AF, Dussek J. Boerhaave syndrome: to treat or not to treat by means of insertion of a metallic stent. J Vasc Interv Radiol 1995;6:741-3; discussion 744-6.
13. Roy-Choudhury SH, Nicholson AA, Wedgwood KR, et al. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents. AJR Am J Roentgenol 2001;176: 161-5. 14. Siersema PD, Homs MY, Haringsma J, et al. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 2003;58:356-61. 15. Gelbmann CM, Ratiu NL, Rath HC, et al. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy 2004;36:695-9.
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Current affiliations: Division of Gastroenterology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA. Reprint requests: Christopher C. Thompson, MD, Division of Gastroenterology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115.