An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study

Background: Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding.

Objective: To assess a new, totally endoscopic strategy to manage anastomotic fistulas.

Design: Prospective study.

Setting: Tertiary-care university hospital.

Patients: This study involved 27 consecutive patients from July 2007 to December 2009.

Intervention: This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant.

Main outcome measurements: Technical success, mortality and morbidity, migration of the stent.

Results: Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient.

Limitations: Moderate sample size, nonrandomized study.

Conclusion: An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.