Discussion
fits, fistula, gastro-cutaneous fistula, leaks, adhesions
RECURRENCE, COMPLICATION, STRICTURE, ANASTOMOTIC LEAK, DILATION, ADHESIONS
In general, the most frightful complication after bariatric surgery is the anastomotic leak with an incidence of 0.8–6% [In our department, we perform about 500 LSG/year, and the incidence of post-LSG leaks or fistula is about 2.5%. Surgical management of gastro-cutaneous fistula after laparoscopic sleeve gastrectomy has increased incidence rates of morbidity and mortality. In this study, we experienced high failure rate of surgical intervention (93.3%) within the first week post-repair (recurrence of fistula within one week in surgical group patients was due to long remaining sleeve pouch with axial rotation or marked narrowing of the pouch so, primary repair and gastrojejunostomy are usually associated with high recurrence rates of fistula because the main cause is not corrected, with axial rotation or marked narrowing of remaining pouch, the intra-gastric pressure increases and site of fistula opens again. This can be solved by classic Roux- en- y gastric bypass but not all patients are candidates for it, and also if the fistula occurred at upper third of the remaining pouch (most common site of fistula), the recurrence rate becomes high and classic Roux- en- y gastric bypass becomes difficult in case of upper third fistula due to marked adhesions and unhealthy remaining tissue at site of fistula). Immediate surgical intervention, with abdominal washout, irrigation, wide drainage and attempts for suturing of the leak if the tissues permit, may be preferred in unstable patients with early type leak [On the other hand, endoscopic intervention has become the corner stone in managing the post-LSG gastric leak or gastro-cutaneous fistula with different modalities such as stenting, clipping, balloon dilatation and endo-suturing. In our study, OTSC, along with dilation, was used in two patients (2/15 of endoscopic group), and none demonstrated clip migration or development of post-OTSC stricture over 3 months follow-up period. We started deploying the clips perpendicular to the long axis of the defect. If needed, multiple clips were placed sequentially, starting at either edge of the defect towards the center. Standard clips were passed through-the-scope to achieve superficial tissue apposition engaging the mucosa and submucosa (with 1.2 mm-wide and 6 mm-long arms capable of an approximately 12 mm grasp) and were used in conjunction with thermal ablation or mechanical scraping of the tissue around the edges of the defect to achieve a more resilient seal. In a retrospective study, OTSC demonstrated a lower success rate (50%) in managing GI fistulas in 30 patients (25/30 patients were post-bariatric surgery: 22 post-sleeve gastrectomy and three post-RYGB) with a median-time-to-OTSC delivery was 147 (range = 5–880) days [In this study, we used a fully covered stent (Mega stent, Taewoong Medical Industries, Gyeonggi-do, South Korea) ultra large and long (length: 24 cm, diameter: 36 mm) stent. We did not experience any complication with Mega stent, particularly migration, thanks to the design of Mega stent that fits well for the post-sleeve anatomy with reduction of migration. It completely covers the whole sleeve pouch and its lower end rests in the duodenum [OverStitching is theoretically an optimum method of leak closure because it is the only true full thickness leak closure and performed endoscopically despite being a complex procedure. In this study, OverStitching was used in 33.3% of patients who underwent endoscopic management. The procedure began with de-epithelialization of the edges of the leak using argon plasma coagulation before applying the OverStitching system. We did not experience post-OverStitch gastric leak. Granata et al. reported 77% success rate of endoscopic management of gastric leak using direct stitches only [This study has some limitations. The small sample size that may not give powerful statistical conclusions. Exclusion of patients with ASA status > II is another limitation. Regarding the de-epithelization of the edges of fistula either for OTSC or OverStitch, there was not a single method, and it was up to the endoscopist to use argon plasma laser or mechanical scrapping of the edges. Moreover, this study showed only 3 months follow-up period. The strength of the present study is being a randomized controlled trial and comparing different endoscopic interventions on one hand with the surgical intervention on the other hand.