Managing Chronic Fistulas after Bariatric Surgery

Matthew Kroh,MDAssistant Professor of Surgery

Cleveland ClinicLerner College of Medicine

Center for Surgical Innovation, Technology, and EducationBariatric & Metabolic Institute

Disclosures

• Research support from and/or consultant:– Covidien– Ethicon– Bard– Gore– Intuitive

Incidence

• Chronic fistulas increasingly common with increased bariatric procedures

• Unique to each operation• Most common is gastro-

gastric fistula• Up to 50% in non-divided

RYGB• From 3-6% in divided

Extent of Problem

• Many patients asymptomatic• Most common complaints:

– Nausea, vomiting– Epigastric pain– Hematemesis

• Other: – Acute- sub-acute sepsis– Recurrent ulceration– Weight regain– Chronic or acute bleeding

• Approach needs to be tailored to presentation

Classification of Fistulas

• Chronicity– 90 days to 12 months– Greater than 12 months

• Etiology– Acute complications with late manifestation

• Leak, sub-clinical• Technical

– Chronic process• Marginal ulceration- Smoking, NSAID’s• Foreign body• Carcinoma

Initial Operations Resulting in Fistulas

• Roux en-Y gastric bypass– G-J– Remnant or pouch staple line– Foreign body in banded bypass procedures

• Sleeve gastrectomy– E-G junction– Incisura obstruction

• Vertical banded gastroplasty– Pouch to stomach via undivided staple line– Eroded band

Types of Fistulas

• Gastro-gastric– Pouch to remnant most common- RYGB– Pouch to native stomach- VBG, non-divided RYGB

• Gastro- and Entero-cutaneous– Any procedure

• Gastro-pleural and Gastro-mediastinal– Any procedure, seem to be more common after

sleeve gastrectomy

Principles of Therapy

• Define anatomy– Initial operation and current fistula involvement

• Control sepsis• Improve nutrition and provide enteral access• Drain and Debride• Reconstruct

– Open– Laparoscpic– Endoscopic

Anatomic Considerations

• Operative notes• Upper endoscopy• Upper GI• CT (maybe)• Fistula tract

injection (maybe)

Stage Repair

• Urgent/emergent intervention for sepsis or bleeding

• Wide drainage– Surgical, endoscopic,

radiologic

• Debridement of non-viable tissue

• Enteral access– Naso-enteric or

surgicalAbscess s/p RYGB

Initial Therapy

• Often medical management– PPI and carafate

typically 3-6 months

• Hyperacidity• From G-G fistula• Or parietal cell

inclusion• Local ischemia at

staples

Therapeutic Intervention

• Timing from initial operation

• Nutritional optimization• Role for endoscopy• Diagnosis and therapy• Dictated by:

• Size• Chronicity• Operative risk of individual

patients

Gastro-gastric Fistula

• Define anatomy– Pouch to remnant

most common- RYGB• At anastomosis or

pouch vertical staple line

– Marginal ulcer or weight regain

– Pouch to native stomach- VBG, non-divided RYGB

• Weight regain

Gastro-gastric Fistula

• UGI– More

sensitive– Especially if

small

• Endoscopy– Operative

planning

Surgical Management

• Symptomatic gastro-gastric fistula after RYGB• Up to 27% leaks manifest with fistula• Typically requires anastomosis resection if

immediately adjacent to G-J• If at vertical staple line, remnant gastrectomy

with fistula

Carrodeguas, SOARD 2005

• 1.1% of 1796 patients undergoing RYGB• 22 of 32 patients required remnant gastrectomy• Mean 9 months from first operation to

gastrectomy• 3 required G-J resection • 2 open procedures• Limited folow-up

Endoscopic Management

• Failed medical management• Small fistula• Sepsis absent• Foreign body removed• Multiple techniques• Fibrin glue efficacy varies• Described with vicryl plugs

Papavramedis 2008 J Gastro HepTruong 2004 Surg Endosc

Sleeve Gastrectomy

• Fistulas from chronic leaks

• May be gastro-cutaneous, pleural

• Difficult to manage• May require total

gastrectomy and Roux esophago-jejunostomy as definitive procedure

Sleeve Gastrectomy

Sleeve Gastrectomy

Future Endoscopic Approaches

US GI Cobra System TMBard EndoCinch TM

Use of specific brand identified instruments for reference only. No promotional bias is inferred.

Endoscopic Approaches

• Endoscopy offers:– Less invasive approach– Endoluminal approach circumvents operative field

• Newer tools are coming for both diagnostic and therapeutic intervention

• Still need to adhere to surgical principles– Tissue apposition– Foreign body removal– Durability?

Conclusions

• Complex

• Require algorithmic approach

• Often require staged, multi-disciplinary approach

• Tailor to:– Type of initial operation– Addressing current patient needs– Long-term goals