managing chronic fistulas after bariatric surgery matthew kroh,md assistant professor of surgery...
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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
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Disclosures
• Research support from and/or consultant:– Covidien– Ethicon– Bard– Gore– Intuitive
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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
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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
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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
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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
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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
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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
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Anatomic Considerations
• Operative notes• Upper endoscopy• Upper GI• CT (maybe)• Fistula tract
injection (maybe)
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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
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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
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Therapeutic Intervention
• Timing from initial operation
• Nutritional optimization• Role for endoscopy• Diagnosis and therapy• Dictated by:
• Size• Chronicity• Operative risk of individual
patients
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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
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Gastro-gastric Fistula
• UGI– More
sensitive– Especially if
small
• Endoscopy– Operative
planning
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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
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• 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
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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
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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
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Sleeve Gastrectomy
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Sleeve Gastrectomy
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Future Endoscopic Approaches
US GI Cobra System TMBard EndoCinch TM
Use of specific brand identified instruments for reference only. No promotional bias is inferred.
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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?
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Conclusions
• Complex
• Require algorithmic approach
• Often require staged, multi-disciplinary approach
• Tailor to:– Type of initial operation– Addressing current patient needs– Long-term goals
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