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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 58-63

Controlled fistula: A valid option for the management of post bariatric surgery leak


1 Department of Surgery, Armed Forces Hospitals, Southern Region, Khamis Mushait, Saudi Arabia
2 Department of Gastroenterology, Armed Forces Hospitals, Southern Region, Khamis Mushait, Saudi Arabia
3 Department of Surgery, Faculty of Medicine, Umm Al Qura University, Mecca, Saudi Arabia

Date of Submission20-Oct-2020
Date of Acceptance19-Dec-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Mohammad Ezzedien Rabie
Department of Surgery, Armed Forces Hospitals, Southern Region, Khamis Mushait
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_45_20

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  Abstract 

Currently, bariatric surgery procedures has witnessed an upsurge in its utilization to control obesity and its allied morbidities. However, gastric or anastomotic leak, though rare, is its most dreadful complication. In this report we describe the clinical course of a 41 year-old-male, with a body mass index of 41.6, who underwent open mini gastric bypass which was followed by leak. A second laparotomy was performed in which intraperitoneal drains were inserted and a feeding jejunostomy was constructed. This was followed by the insertion of a mega stent, along with the application of over the scope clip at the site of the leak. Few days later, he appeared in our hospital with manifestations of sepsis. Computerized tomography scan showed persistence of leak with a perisplenic collection. A third laparotomy was performed and after tedious dissection, the stent was found eroding through the site of gastrojejunostomy. The defect was closed over a T tube and the perisplenic collection was drained. The patient tolerated surgery well, but he developed wound infection with disruption. Conservative treatment was followed to create a controlled incisional hernia, to be dealt with later. After a lengthy hospital stay, radioloic studies showed cessation of the leak with no collection. T tube, drains and jejunostomy tube were removed in time and the patient was discharged in good condition for OPD follow-up.

Keywords: Controlled fistula, leak, minigastric bypass, obesity, T tube


How to cite this article:
Rabie ME, Al Hazmi A, El Hakeem I, Shakik R, Elias A, Al Qahtani AS, Malatani TS, Al Khiar S. Controlled fistula: A valid option for the management of post bariatric surgery leak. Saudi Surg J 2020;8:58-63

How to cite this URL:
Rabie ME, Al Hazmi A, El Hakeem I, Shakik R, Elias A, Al Qahtani AS, Malatani TS, Al Khiar S. Controlled fistula: A valid option for the management of post bariatric surgery leak. Saudi Surg J [serial online] 2020 [cited 2021 Feb 24];8:58-63. Available from: https://www.saudisurgj.org/text.asp?2020/8/1/58/307425


  Introduction Top


Currently, morbid obesity surgery is being increasingly utilized to control obesity and its related morbidities. Different procedures are available, including Roux en Y gastric bypass, sleeve gastrectomy, and mini gastric bypass (MGB, [Figure 1]). Compared to the original Roux-en-Y gastric bypass, MGB has been claimed to be a simpler procedure which is as effective while having less complications.[1] These complications might vary from minor to major ones,[2] with the dreadful gastric leak, though rare, is one of its most common complications.[3]
Figure 1: Minigastric by pass. Sleeved stomach: Red, gastric tube: Pink, small bowel: Orange

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  Case Report Top


A 41-year-old male, with an original body mass index of 41.6 and no past medical history, presented to our hospital with abdominal pain, distension, cough and shortness of breath. Few weeks earlier, he underwent open MGB in another country. As per the hospital report, the procedure was complicated by postoperative leak and relaparotomy was done. The leaking point, which was found just below the cardia, was managed by mega oesophageal stent insertion coupled with over the scope clip application to the site of the leak. At the conclusion of laparotomy, multiple drains were inserted and a feeding jejunostomy was created. Two weeks later, he flew back to his country, Saudi Arabia.

On examination, he was tachypnoeic, tachycardic and looked unwell and his temperature was 41.1°C, blood pressure was 140/74 mm Hg, respiration rate was 20/min and O2 saturation was 94%.

His chest was wheezy and his abdomen was distended and tender, with an infected upper midline incision.

Laboratory investigations showed leukocytosis (14.0 × 109/L, reference range 4–11 × 109), high C-reactive protein (140.2 mg/L, reference range <10) and raised lactate dehydrogenase (359 mmol/L, reference range 98–192). Other investigations, including liver and renal values, serum amylase, haemoglobin, platelet count, and coagulation profile were within normal.

Computerized axial tomography scan (CT) showed an esophagogastric stent impinging on the jejunum, with contrast leak and a large perisplenic collection [Figure 2] and [Figure 3].
Figure 2: Axial computed tomography showing contrast leak into the wound (white arrow) with perisplenic collection (red arrow)

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Figure 3: Stent (filled with contrast) occupying the gastric tube and impinging on the jejunum (white arrow)

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Initially, percutaneous drainage of the perisplenic collection was attempted, but unfortunately the catheter was blocked and as the situation was not controlled, a decision was taken for laparotomy.

Upon entering the abdomen through the previous incision, marked difficulty was encountered to dissect the adherent bowel loops, to expose the lower end of the gastric tube and the site of the gastrojejunal anastomosis. The edge of the metallic oesophageal stent was seen eroding the lower end of the gastric tube and abutting on the gastrojejunal anastomosis [Figure 4]. Endoscopic removal of the stent was then performed by the gastroenterologist [Figure 5] followed by a nasogastric tube insertion. The gastric tear was then repaired over a T tube size 14, utilizing polydioxanone sutures, with the transverse limb of the T lying across the gastrojejunal anastomosis [Figure 6].
Figure 4: The metallic stent eroding through the site of gastrojejunal anastomosis (yellow circle)

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Figure 5: The extracted oesophago gastric stent

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Figure 6: (a and b) Repair of the defect around a T tube, with the transverse limb of the T lying across the gastrojejunal anastomosis

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With careful blunt dissection between the lateral abdominal wall and adherent bowel loops, the perisplenic collection was entered and suctioned out with repeated saline irrigation and a suction drain was inserted. Another suction drain was also inserted near the repaired gastric tear and the abdomen was closed.

In the postoperative period, the long limb of the T tube was connected to a bile bag for continuous free drainage. Jejunostomy feeds started in the third postoperative day and the patient was kept on nil orally with nasogastric aspiration, along with the administration of anticoagulatnts, antibiotics and physiotherapy. Unfortunately, wound infection leading to total wound disruption occurred. Due to the marked difficulty encountered during the previous surgery, in addition to the presence of severe infection, a decision was taken to follow a conservative approach, creating a controlled incisional hernia [Figure 7], which could be dealt with later. To protect the viscera from desiccation and fistula formation, the wound gap was covered with paraffin gauze on top of which saline soaked gauze was applied. Initially, the dressing was changed daily, and less frequently later with clearance of the wound.
Figure 7: Healthy granulations covering the gaped wound (a) which later epithelialized (b), forming an incisional hernia. In Figure 6a, the T tube is still in place (white arrow)

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The situation was brought under control and the postoperative recovery was relatively smooth. Five weeks after surgery, follow-up CT scan, utilizing oral contrast along with contrast injection into the T tube, showed no contrast leak [Figure 8], and graded oral feeding started with removal of the T tube. Almost 6 weeks after admission, the patient was discharged in good condition for follow-up.
Figure 8: Followup contrast study with no evidence of gastric leak

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  Discussion Top


MGB was first introduced by Rutledge in 2001,[4] as a simpler variant of the classic Roux en Y gastric bypass. However, the enthusiasm for it has been marred by the higher incidence of biliopancreatic reflux into the oesophagus and gastric pouch, with its feared potential consequence of esophagogastric cancer,[5],[6]

Like other bariatric procedures, gastric or anastomotic leak is a major problem of MGB, with an incidence of 1.5%. It may occur at the gastric stable line Type 1), or the gastrojejunostomy site (Type 2) and may present as early as the first 24 h or as late as 7 months later.[7] In a rare report, stable line leak was observed 16 months after the procedure.[8] In this regard, it has been observed that early gastric leak is usually associated with systemic inflammation, whereas late leak manifests with pulmonary complication and intraperitoneal abscess formation,[9] with tachycardia, being the most common clinical sign of acute intra-abdominal sepsis associated with leak (65%).[10]

The early detection of leak, and consequently the early institution of treatment, has been associated with improved healing rate.[11],[12] For this reason, in suspected cases, an upper gastrointestinal series or CT with water soluble contrast should be employed, as both are usually diagnostic,[13] with the later having a diagnostic accuracy of 93%.[10] At times, leaks may be visualized during endoscopy.[14] In this regard, Warschkow et al. found that increased C reactive protein 2 days post Roux en Y gastric bypass, reliably detected leak.[15] However, in the experience of Dib et al., C reactive protein was unhelpful in excluding leak.[16]

Several classifications have been proposed for gastric or anastomotic leaks. However, a most pertinent classification is that which divides them according to the severity of the clinical manifestations and the timing of presentation. In their work, Csendes et al. classified leaks into subclinical leak, which is not accompanied by septic complications, and clinical or septic leak which is a more serious situation with a higher mortality rate.[17]

Unfortunately, the management of gastric/anastomotic leaks following morbid obesity surgery has not been standardized. However, a multidisciplinary approach is always required and different techniques, varying from minimally invasive to open surgery, have been described with varying success rates, even for the same technique. In his own series of 1274 patients following MGB, Rutledge reported a hospital mortality rates of 0.08% and a leak rate of 1.6%, which was treated laparoscopically in all patients.[4] In another work on 1200 patients, Carbajo et al.[3] reported a mortality rate of 0.16% and an anastomotic/gastric leak rate of 1.07%. In this work, the majority of patients (10 patients, 0.83%) were managed conservatively by keeping the patient on nil orally and initiating total parentral nutrition, with or without the endoscopic insertion of an oesophageal stent. However, some patients were managed by either left subcostal mini laparotomy or laparoscopy accompanied by endoscopic insertion of oesophageal stent in either case.[3]

In another report on 557 patients who underwent open gastric bypass, 12 patients developed leak at the gastrojejunostomy site, all of them were treated medically, with antibiotics, entral or parentral feeding along with prolonged drainage.[18] However, the same group reported its experience on seven patients with post sleeve gastrectomy leaks, where four required reoperation while the other three were managed conservatively according to the previous lines.[19] Other minimally invasive techniques, centred around the utilization of self expandable oesophageal stents along with either percutaneous drainage[20] or laparoscopic drainage have been reported.[21] However, Beaupel et al. managed the majority of their patients surgically (16 patients), and only one patient was treated medically.[10]

Unfortunately, our experience on this issue is derived from case reports and small case series, which makes it difficult to draw guidelines or make rigid conclusions. However, in an attempt to perform comparative studies on different treatment options, Schiesser et al. compared the results of endoscopic treatment (five patients) to those of surgical treatment (nine patients) who presented with post Roux en Y gastric bypass leak. Endoscopic treatment consisted of stent placement and/or over the scope clip application, combined with percutaneous draining when indicated. On the other hand, surgical treatment consisted of laparoscopic reoperation with either suture closure of the defect, followed by local irrigation and drainage (7 patients) or renewal of the anastomosis (2 patients). The success rate was 88% and 100% for the surgical and endoscopic treatment, respectively, and there was one death in the surgical group with none in the endoscopic group which had a longer time to closure as well as a longer hospital stay.[22]

In this regard, although esophagogastric stents are effective in controlling post bariatric surgery leaks, they should be used with caution, as perforation and bleeding are known complications,[23] as seen in the patient presented here. Other stent related complications include oesophageal stricture, intolerance necessitating premature removal, ulceration and even death.[14],[23] Moreover, as the current esophageal stents are designed to treat esophageal strictures, they are consequently of limited length, making stent migration and treatment failure a real possibility. A longer stent designed to cover the area from the mid esophageos down to the first part of the duodenum (mega stent) has been employed and claimed to be more effective than the current stent.[24],[25] Interestingly, there is an increasing utilization of oesophageal stents, either the mega stent or the standard one, together with the application of over the scope clip to the site of the leak.[23],[26] In the patient presented here, a mega stent was applied together with an over the scope clip. However, this mega stent caused the gastrojejunal anastomosis to break.

Other rarely employed and more invasive techniques for treating chronic and persistent gastric fistula include Roux en Y fistulojejunostomy[27],[28],[29] and total gastrectomy with Roux en Y oesophagojejunostomy.[30]

In another still rarer attempt to control gastric leaks, Zachariah et al. introduced a novel technique, in which a gastrostomy was created utilizing a laparoendoscopic technique, aiming at prolonged gastric tube decompression. This was combined with the placement of external drains and a feeding jejunostomy. In their experience, this technique succeeded in 6 out of seven patients, while the last one with large rent which failed to heal, underwent fistulojejunostomy instead.[31]

To our surprise during our literature review, we came across an essentially similar case to ours, though less complex, where a T tube was placed into the disrupted sleeve gastrectomy stable line. Similarly, this was combined with intraperitoneal drainage and the creation of a feeding jejunostomy.[32] The success encountered in this case as well as in ours, probably testifies to the effectiveness of this simple technique.

The success we encountered with this patient should also be attributed to the management strategy of the wound, where it was left to clear and granulate, and later to epithelialize, while protecting the bowel from desiccation. This technique avoids the immediate surgical repair, in the presence of the adverse factors of wound infection and severe adhesions involving the bowel. The success of this technique with its several modifications, including the application of negative pressure dressing, has been previously reported.[33],[34],[35]

In the absence of clear guidelines and till more experience is gained, it might be advisable for each institution to utilize the experience and expertise available, to create its own protocol. In this respect, certain principles exist, depending on the patient's stability and the timing and magnitude of the leak. These include:

  1. Once clinically suspected, an oral contrast enhanced CT or upper gastrointestinal series should be performed, to locate the site and size of the leak and the presence of any collection
  2. Collections should be drained either surgically (laparoscopic or laparotomic) if surgery is considered, or percutaneously under radiology control, if surgery is not contemplated
  3. In stable patients, endoscopic control with self expandable oesophageal stents and/or over the scope clips may be the best option
  4. In unstable patients, the surgical options, open or laparoscopic, should come into play
  5. During surgery, direct closure of early leak with sutures or clips may be attempted
  6. Leaks of some standing will not hold sutures or clips well, leading to persistence of leak. In such cases, a controlled fistula to the skin (the technique described here) may be the best option.



  Conclusion Top


Gastric/anastomotic leak following bariatric procedures is a serious condition, which is difficult to tackle. In these situations, a multidisciplinary approach is usually required. Closing the site of leak around a T tube, to create a controlled fistula may be a valid option in certain cases. Wound disruption encountered in these cases, may be equally treated conservatively, to create a controlled incisional hernia, which could be repaired later, after the resolution of sepsis and inflammation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Tsai YN, Wang HP, Huang CK, Chang PC, Lin IC, Tai CM. Endoluminal stenting for the management of leak following sleeve gastrectomy and loop duodenojejunal bypass with sleeve gastrectomy. Kaohsiung J Med Sci 2018;34:43-8.  Back to cited text no. 14
    
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Warschkow R, Tarantino I, Folie P, Beutner U, Schmied BM, Bisang P, et al. C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity. J Gastrointest Surg 2012;16:1128-35.  Back to cited text no. 15
    
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Dib F, Parenti LR, Boutten A, Hajage D, Marmuse JP. Diagnostic performance of C-reactive protein in detecting post-operative infectious complications after laparoscopic sleeve gastrectomy. Obes Surg 2017;27:3124-32.  Back to cited text no. 16
    
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Matłok M, Major P, Pędziwiatr M, Winiarski M, Budzyński P, Małczak P, et al. Endoscopic insertion of a self-expandable stent combined with laparoscopic rinsing of peritoneal cavity as a method for staple line leaks treatment in patients post laparoscopic sleeve gastrectomy. Pol Przegl Chir 2015;87:238-44.  Back to cited text no. 21
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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