Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract

Abstract

Trans-fistulary drainage of post-bariatric abdominal collections is safe and associated with high success rates. This technique can be considered in previously untreated patients, when a collection is not properly drained percutaneously, or after failure of other endoscopic treatments.

Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results

“…At each session stent exchange was performed until fistula healing was achieved to avoid stent obstruction and to stimulate tissue granulation by the traumatism induced by the stent on the fistula edges. In a more recent study on 33 patients with fluid collections after SG or RYGB (in 19 patients after previous unsuccessful endoscopic treatment), internal drainage achieved 78.8% clinical success[87]. After confirming biological and clinical improvement, this approach allowed early oral re-feeding in the first 24-48 h following stent insertion without any negative impact on the final results.…”

“…For early leaks, this is commonly accomplished by surgical drains maintained in the postoperative period but if drains are no longer in place, percutaneous drains should be placed either surgically or by interventional radiology whenever accessible. Nevertheless, in patients with delayed leakage or when surgical cleansing is not required or for those whose collections are not radiologically accessible, the endoscopic internal drainage (EID) into the digestive lumen might be the first option for well-circumscribed collections[87]. In addition when combined with surgical cleansing in patients presenting with severe sepsis, EID allows early removal of surgical drainage preventing chronic fistula tract formation[88].…”

“…In addition when combined with surgical cleansing in patients presenting with severe sepsis, EID allows early removal of surgical drainage preventing chronic fistula tract formation[88]. EID consists of trans-fistulary insertion under fluoroscopy guidance of one or two 7 or 8.5 Fr double-pigtail plastic stents, or one double-pigtail stent and one nasocystic catheter in cases of large collections requiring lavage to eliminate pus and debris[87] (Figure 2). Double-pigtail stents keep the leak orifice open favoring the passage of fluid content into the digestive lumen with progressive reduction in the collection size until it eventually becomes a virtual cavity.…”

“…A residual small cavity like a pseudodiverticulum is common at the end of the process without any clinical repercussion[88]. In some cases, the leak orifice is not clearly identified or the communicating tract between the digestive lumen and the fluid collection is complex, then, internal drainage may be accomplished by EUS-guided drainage, such as for pseudocysts or other postsurgical collections[87-90]. In addition to stenting, debridement may also be needed in cases of infected collections containing necrotic tissue.…”

“…Although EID is now most commonly used as a first-line approach, it has also been reported as a bridge to other endoscopic methods and as a salvage treatment when other endoscopic techniques have failed[87-89]. In the largest series reporting on EID, double pigtails were delivered as a first line approach in 66 patients[88].…”