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Original article

Trans-fistulary endoscopic drainage for post-bariatric


abdominal collections communicating with the upper
gastrointestinal tract

Authors Simon Bouchard1, 2, *, Pierre Eisendrath1, *, Emmanuel Toussaint1, Olivier Le Moine1, Arnaud Lemmers1,
Marianna Arvanitakis1, Jacques Devière1

1
Institutions Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Université Libre de Bruxelles, Hôpital
Erasme, Brussels, Belgium
2
Department of Gastroenterology, University of Montreal Hospital, Montreal, Canada

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submitted Background and study aims: Diverse endoscopic lections occurred after sleeve gastrectomy (n =
26. October 2015 methods, such as placement of temporary self- 28) or after gastric bypass (n = 5). Fourteen pa-
accepted after revision
expandable stents, have proven effective for the tients were treated by trans-fistulary stenting as
28. April 2016
treatment of post-bariatric surgery leaks. How- primary treatment, and 19 patients had under-
ever, some patients do not respond to the usual gone previous unsuccessful endoscopic treat-
Bibliography endoscopic treatment. This study tested the effi- ment. No serious complication occurred during
DOI http://dx.doi.org/ cacy of an alternative treatment strategy based the drainage procedure. Clinical success was
10.1055/s-0042-108726
on trans-fistulary drainage with double-pigtail achieved in 26 patients (78.8 %). In two success-
Published online: 2016
Endoscopy
plastic stents. fully treated patients, stents are still in place.
© Georg Thieme Verlag KG Patients and methods: We performed a retro- Spontaneous stent migration occurred in 12 pa-
Stuttgart · New York spective analysis of patients with abdominal col- tients. In 12 patients, the stents were removed,
ISSN 0013-726X lections following bariatric surgery who were either electively (n = 5) or because of complica-
treated by trans-fistulary stenting between May tions (ulcerations n = 3, upper gastrointestinal
Corresponding author
Pierre Eisendrath, MD
2007 and February 2015. Clinical success was de- symptoms n = 3, splenic hematoma n = 1).
Department of fined as a sustained (> 4 months) clinical resolu- Conclusions: Trans-fistulary drainage of post-
Gastroenterology, tion (patient discharged from the hospital with- bariatric abdominal collections is safe and asso-
Hepatopancreatology, out antibiotics and able to resume a normal ciated with high success rates. This technique
and Digestive Oncology diet) and radiological response. Patient records, can be considered in previously untreated pa-
Université Libre de Bruxelles radiological images, and the hospital endoscopy tients, when a collection is not properly drained
Hôpital Erasme
database were reviewed. percutaneously, or after failure of other endo-
Route de Lennik 808
1070 Brussels
Results: A total of 33 patients (26 women/7 men, scopic treatments.
Belgium mean age 42 years [SD 11.2]) were included. Col-
Phone: +32-2-5553712
pierre.eisendrath@erasme.ulb. Introduction with percutaneous drainage. This approach is
ac.be ! associated with closure rates ranging from 62 %
As the prevalence of obesity has continued to rise to 87 % [10 – 13]. Other available endoscopic tech-
in the past few years, bariatric surgery has be- niques for the treatment of post-bariatric leaks or
come an increasingly popular treatment option fistulas include endoscopic clipping of the closure
in selected patients, and aims to dramatically re- defect [14, 15], use of fistula plugs [16], or fibrin
duce the morbidity and mortality associated with injection [17, 18].
this serious health issue [1 – 3]. However, some patients do not respond to the
However, bariatric surgery can be associated with usual endoscopic treatments because of anatomic
surgical complications, such as leaks or persistent particularities, such as size and location of the
fistulas, which may occur in 1 % – 6 % of patients closure defect, delay in endoscopic management
[4 – 9]. leading to chronic fistulous tracts, or abdominal
The most widely used endoscopic technique to collections that are not accessible for percuta-
treat post-bariatric fistulas or leaks is tempor- neous drainage [13, 19 – 21]. In these patients, in-
ary stenting with partially or fully covered ternal drainage of the abdominal collection by in-
self-expandable metallic stents (SEMS) coupled serting plastic stents through the fistulous tract
offers a possible endoscopic option. Experience
with this technique has been reported in a pilot
* These authors contributed equally to this work. study and in a recent case series where it was

Bouchard Simon et al. Trans-fistulary endoscopic drainage for abdominal collections … Endoscopy
Original article

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Fig. 1 Trans-fistulary drainage in a 40-year-old woman with an early leak after sleeve gastrectomy. a Initial endoscopic treatment using a self-expandable
metallic stent (SEMS). b, c After removing the SEMS, contrast medium was injected through the gastroscope. A fistulous tract could still be seen at the upper
portion of the staple line, communicating with an abdominal collection. d Under fluoroscopic guidance, a 0.035-inch guidewire was advanced into the collec-
tion until its distal end created a loop. This guidewire was used to insert a double-pigtail plastic stent (7 or 8.5 Fr), with one extremity in the collection and the
other in the digestive lumen. The same technique was repeated to advance a second double-pigtail plastic stent. e Final fluoroscopic image after placement of
two trans-fistulary double-pigtail stents.

used as a first-line approach to post-bariatric surgery leaks [22, treatment and without percutaneous drainage were the first
23]. This endoscopic approach is similar to that reported in a pre- patients for whom trans-fistulary drainage was proposed as an
viously published experience in which endoscopic ultrasound alternative treatment. Following several successful cases in this
(EUS)-guided drainage of post-operative abdominal collections patient group, the treatment modality was also proposed as a
was used [24]; the difference in the current study is the use of first-line approach for treatment-naïve, nonseptic patients with
an existing fistulous tract. leaks who presented with well-circumscribed collections and no
Thus, in selected patients who have previously undergone bariat- or incompetent percutaneous drainage. If present, percutaneous
ric surgery and have abdominal collections communicating with drains were removed as soon as possible.
the upper gastrointestinal tract, we hypothesize that successful For all patients, medical records, and radiological and endoscopic
treatment could be achieved using trans-fistulary drainage with images were reviewed before inclusion. The presence of a leak
double-pigtail plastic stents. We initially used this technique communicating with an abdominal collection was confirmed by
after failure of initial endoscopic management using SEMS, and upper gastrointestinal swallow study, endoscopy with water-sol-
later used it in selected patients for first-line management. uble contrast media, or abdominal computed tomography (CT)
scan. Leaks were characterized as early, acute, late or chronic
[25]. Each case had also been discussed during a meeting of the
Materials and methods endoscopy team before trans-fistulary drainage was performed.
! This study was approved by the ethics committee of Erasme Hos-
We performed a retrospective analysis of patients with post-bar- pital. All patients included in the study were aged 18 years or over.
iatric abdominal collections communicating with the upper gas- Technical success was defined as the successful insertion of at
trointestinal tract who were treated by trans-fistulary drainage least two pigtails (either stent or catheter) into the collection.
between May 2007 and February 2015 at Erasme Hospital, a Clinical success was defined as a sustained (> 4 months) clinical
tertiary care center with expertise in treating patients with resolution (patient discharged from the hospital without antibi-
post-bariatric surgery complications. otics and able to resume a normal diet) and radiological response.
During this inclusion period, our initial treatment policy for post- Radiological response was defined as the absence of any abdom-
bariatric leakage was based on previous experience [13], and inal collection at follow-up abdominal imaging (CT, endoscopy or
involved the placement of SEMS (partially covered, with use of swallow study with contrast medium). Persistence of only a “vir-
the stent-in-stent technique for removal) together with percuta- tual” air cavity, which was occupied only by the pigtail loops, was
neous drainage. Patients with recurrent collections despite SEMS also considered a radiological response.

Bouchard Simon et al. Trans-fistulary endoscopic drainage for abdominal collections … Endoscopy
Original article

Description of procedure (●
" Fig. 1) Statistical analyses
Endoscopic procedures were performed under fluoroscopic guid- General characteristics are expressed as median and range for
ance with patients under general anesthesia with orotracheal in- continuous data or percentages for categorical data. The differen-
tubation. ces between patients with treatment success or failure were sta-
The choice of endoscope was dependent on the fistula orifice tistically analyzed using the Mann–Whitney test for continuous
location: therapeutic gastroscope (GIF-1TH190; Olympus, Ham- data and the chi-squared test or the Fisher’s exact test, as neces-
burg, Germany), duodenoscope (TJF-160R; Olympus) or echo-en- sary, for categorical data. The data were analyzed using SPSS 22
doscope (GF-UCT180; Olympus). All procedures were performed statistical software for Windows (IBM Corp., Armonk, New York,
with CO2 insufflation. Using fluoroscopy, vigorous intraluminal USA). All statistical tests were two sided. P values of < 0.05 were
injection of contrast medium was initially performed in order to considered to be statistically significant.
better characterize the fistula tract (length, direction, relation to
the surgical anastomosis or staple line) and the communicating
abdominal collection. A balloon catheter or a 5-Fr cannula was Results
then inserted into the fistula orifice and aspiration of liquid was !
performed for bacteriological analysis. In rare situations where A total of 33 patients who met the inclusion criteria were identi-
the leak orifice was difficult to visualize endoscopically, the gas- fied for the period between May 2007 and February 2015. Over-
troscope was exchanged for an echo-endoscope to perform a all, they represented approximately a quarter of the 135 patients

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puncture of the collection. who underwent endoscopic treatment for post-bariatric surgery
Under fluoroscopic guidance, a 0.035-inch guidewire was ad- leaks during the study period.
vanced into the communicating collection until its distal extrem- The baseline characteristics and clinical presentation of included
ity created a loop. With the first guidewire in place, a second patients are shown in ● " Table 1. All but one patient with a sleeve

0.035-inch guidewire was advanced into the collection using the gastrectomy had a leak originating from the upper portion of the
same technique. If necessary, the fistula tract was dilated to 8 mm staple line. All of the leaks in patients with a gastric bypass origi-
using a biliary balloon dilator, which enabled more than one plas- nated from the gastrojejunal anastomosis.
tic stent to be advanced. Of the 14 patients treated by trans-fistulary drainage as a first-
Using the guidewires in place, trans-fistulary drainage was line endoscopic approach, 10 were directly drained internally by
achieved by placing two 7-Fr (Cook Medical, Limerick, Ireland) double-pigtail stents and 4 underwent surgical re-exploration (3
or 8.5-Fr (Endo-Flex, Voerde, Germany) double-pigtail plastic for abdominal cavity drainage and 1 in an attempt to repair the
stents, or by placing a combination of one double-pigtail stent leak) before stent placement.
and one 6-Fr nasocystic catheter (Cook Medical). In these latter Failed previous endoscopic treatments were all due to unsuccess-
patients, the nasocystic catheter was removed within a few days ful SEMS-based treatment, with a median of 3.5 stents per pa-
during a second endoscopic session and replaced with a second tient (range 1 – 9). A fistula plug was inserted in addition to
double-pigtail stent. The initial combination of a nasocystic SEMS in four patients. Two patients experienced unsuccessful
catheter and a double-pigtail stent was chosen for patients with endoscopic metallic clip placement.
a large collection that required flushing to eliminate pus and Trans-fistulary drainage was performed using a gastroscope in 24
debris. The length of the stents used was determined by charac- patients, a duodenoscope in 6 patients, and an echo-endoscope
teristics and length of the fistula tract. in 3 patients. These latter three patients did not formally fulfill
During the first days following the drainage procedure, patients the definition of trans-fistular drainage but were similar in prin-
received parenteral nutrition. In the majority of patients, a fol- ciple because EUS-guided drainage was used only because of the
low-up abdominal CT scan was performed within the first week difficult identification of the leak orifice and/or the complex tract
following trans-fistulary drainage to confirm a decrease in the to the collection. Patients with collections and no patent leaks
size of the abdominal collection. Patients were then allowed to drained under EUS [24] were not included in this series. In two
resume a progressive oral diet. of these three patients, previous endoscopic SEMS-based treat-
Following the drainage procedure, there was no standardized ment had failed. None of them had percutaneous drainage in
stent removal protocol. The decision to remove (or not) the dou- place when internal pigtail stents were inserted.
ble-pigtail stents was left to the discretion of the endoscopist. For Two double-pigtail stents were initially placed in 25 patients
those in whom retrieval was planned, the exact timing of stent (75.8 %), and 8 patients (24.2 %) were initially treated with a dou-
extraction was decided on an individual basis, but in all cases re- ble-pigtail stent and a nasocystic catheter. Balloon dilation of the
trieval occurred at least 4 months after complete clinical and bio- leak orifice was performed in eight patients (24.2 %). Immediate
logical resolution. technical success was achieved in all patients.
Data were collected by reviewing patient records, and the Erasme No severe immediate complications (significant bleeding, per-
Hospital endoscopy (Endobase; Olympus Europe, Hamburg, Ger- foration, or death) occurred at the time of the procedure. In one
many) and radiological databases. patient, internal migration of one of the two stents into the ab-
After hospital discharge, follow-up data were obtained either by dominal collection occurred during stent placement. This stent
reviewing follow-up visits and abdominal radiologic examina- was retrieved 10 days later using rat-tooth forceps. Five patients
tions for patients followed locally, or by communicating with still had a percutaneous drain in place when internal pigtails
the patient’s physician for those who were referred from another were inserted. The drain was removed with a median delay of 3
hospital. days. After pigtail placement, patients were hospitalized for a
median duration of 8 days (range 1 – 27 days). A follow-up ab-
dominal CT scan was performed after a median duration of 3
days (range 1 – 7 days) following pigtail placement. After the

Bouchard Simon et al. Trans-fistulary endoscopic drainage for abdominal collections … Endoscopy
Original article

Age, mean (SD), years 42.0 (11.2) Table 1 Baseline demographic


Sex, female/male, n 26/7 and clinical characteristics of
BMI before bariatric surgery, mean (SD), kg/m 2 41.2 (7.1) patients.
Type of bariatric surgery, n (%)
Sleeve gastrectomy 28 (84.8)
Gastric bypass 5 (15.2)
Previous bariatric surgery, n (%) 1 7 (21.2)
Time between bariatric surgery and postoperative complication, median (range), days 6 (1 – 60)
Clinical presentation of postoperative complication, n (%)
Abdominal pain 27 (81.8)
Fever 23 (69.7)
Septic shock 8 (24.2)
Diameter of abdominal collection, median (range), mm 68 (21 – 180)
Leak classification (time of presentation after bariatric procedure) 2
Acute leak (< 7 days) 18 (54.5)
Early leak (1 – 6 weeks) 14 (42.4)
Late leak (6 – 12 weeks) 1 (3)
Chronic leak (12 weeks) 0 (0)
Previous endoscopic treatment of fistula or leak, n (%)

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No (primary treatment) 14 (42.4)
Yes 3 19 (57.6)
Time between bariatric surgery and trans-fistulary drainage, median (range), days
All patients 47 (5 – 1071)
Failure of previous endoscopic treatment 96 (27 – 1071)
Primary treatment 14 (5 – 49)
Combination with percutaneous drainage, n (%) 5 (15.2)
Delay to percutaneaous drain removal, median (range), days 3 (0 – 17)
BMI, body mass index.
1
Vertical banded gastroplasty (n = 4); laparoscopic adjustable gastric band (n = 3).
2
According to the Rosenthal classification.
3
Esophageal stent(s) (n = 19); fistula plugs (n = 4); endoscopic metallic clips (n = 2); naso-cystic catheter (n = 1)

trans-fistulary drainage procedure, patients resumed a progres- One patient developed a splenic hematoma 78 days after trans-
sive oral diet after a median of 3 days (range 0 – 13 days). fistulary drainage. This serious complication might be explained
●" Fig. 2 summarizes the clinical outcomes of treated patients. by the close proximity of the double-pigtail stents to the splenic
Clinical success was achieved in 26 patients (78.8 %). Clinical suc- parenchyma. Although initial clinical success was achieved in this
cess was achieved in 12 previously untreated patients (85.7 %) patient, surgery was necessary and the plastic stents were re-
and 14 patients with previous endoscopic treatment failure moved during surgery. This patient made a full recovery.
(73.7 %). Two patients treated by trans-fistulary drainage developed a
In the 26 successfully treated patients, complete resolution of the stricture of the upper part of the sleeve at follow-up: one patient
abdominal collection was achieved in 25 patients. In one patient, underwent successful balloon dilation and the other patient re-
a significant decrease in the size of the abdominal collection was quired a combination of balloon dilation and the temporary
noted 1 month following drainage. placement of an SEMS. Finally, one patient who achieved clinical
The median follow-up time following trans-fistulary drainage success was seen in the emergency room for a bleeding ulcer at
was 358 days (range 111 – 1712 days). In two successfully treated the site of the initial leak orifice 5 months after trans-fistulary
patients, stents were still in place after a stenting duration of 173 drainage. Stent migration was noted at that time, and the bleed-
and 1712 days, respectively, with no complications. These pa- ing resolved with endoscopic coagulation and the use of proton
tients were reluctant to undergo a procedure to remove the pump inhibitors.
stents, as they felt perfectly well with the stents in place. In 12 pa- In seven patients (21.2 %), trans-fistulary drainage was not suc-
tients with spontaneous stent migration, no complication had oc- cessful. In five of these patients, previous endoscopic treatments
curred after a median follow-up of 287 days (range 193 – 742 (SEMS, clips, or fistula plugs) had failed. Four patients with treat-
days). The median follow-up time after radiological or endo- ment failure underwent further endoscopic treatment, and sur-
scopic observation of stent migration was 139 days (range 0 – gery was necessary in six patients. ● " Table 2 describes further

653 days). The median duration between pigtail insertion and treatments performed in patients with unsuccessful trans-fistu-
observation of stent migration was 141 days (range 69 – 437 lary drainage. In one patient, trans-fistulary drainage was per-
days). In 12 patients, the plastic stents were removed after a formed late after the initial bariatric surgery (150 days) and the
median stent dwell duration of 115 days (range 23 – 773 days), fistula was complex (communicated with the respiratory tract).
and no complications occurred during a median follow-up of In another patient, although initial trans-fistulary drainage was
233.5 days (range 45 – 860 days) after stent removal. In these pa- not successful, two other trans-fistulary treatment attempts al-
tients, stents were removed electively (n = 5) or because of symp- lowed the patient to return home temporarily before undergoing
tomatic stent-induced esophageal ulcerations (n = 3), dysphagia corrective bariatric surgery. During the 6-month follow-up of
(n = 2), or retrosternal discomfort (n = 1), or because of the occur- another patient after trans-fistulary drainage, a febrile episode
rence of a splenic hematoma (n = 1). was noted, along with fluctuating levels of serological inflamma-

Bouchard Simon et al. Trans-fistulary endoscopic drainage for abdominal collections … Endoscopy
Original article

33 included patients treated by trans-fistulary stenting 7 patients (21.2 %) Fig. 2 Clinical outcomes of included patients.

26 patients (78.8 %) Treatment failure

Clinical success

Stents are still in place Spontaneous stent migration Stent retrieval


2 patients 12 patients 12 patients

▪ 5 elective retrievals
▪ 7 retrievals due to:
– ulcerations (3)
– dysphagia (2)
– discomfort (1)
– splenic hematoma (1)

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Surgical management of leaks in the post-bariatric surgery set-
Table 2 Failures of trans-fistulary drainage.
ting is risky and difficult [5, 26]. As the evidence base demon-
Failure # Further Fistulous Necro- Surgery strating the success of endoscopic treatment for post-bariatric
endoscopic tract dilation sectomy leaks and fistulas has grown [10 – 18], surgeons have gained in-
treatments creasing confidence in this less-invasive approach. Covered
1 – – – + SEMS insertion, associated with an external drain placed by
2 + (SEMS, NCC) + (19 mm) – + radiological or surgical intervention, is currently the most docu-
3 + (SEMS, + (15 mm) + (3 sessions) + mented method of treatment. The SEMS coating isolates the leak
Necrosectomy) orifice from gastric liquid and allows re-feeding during fistula
4 – – – + healing. This technique has been associated with success rates of
5 + (SEMS) – – – approximately 80 % in several studies published during the past
6 – – – +
decade [10 – 12].
7 + (SEMS) + – +
Nevertheless, such treatment is indicated only in patients with
SEMS, self-expandable metallic stent; NCC, naso-cystic catheter. adequate external drainage of any leak-associated fluid collec-
tion. With the exception of early post-surgical leakage, peri-
operatively placed drains have often already been retrieved at
tory markers and direct visualization of pus from the fistula the time a leak is diagnosed. In these cases, and if the patient
orifice. Treatment was considered to have failed and the patient does not require abdominal cavity surgical cleaning, placement
required surgery. of a percutaneous drain under radiological guidance may be re-
In the patients with previous endoscopic treatment of fistula or quired. In some patients, this procedure may not be possible be-
leak, a median number of 4 (range 1 – 9) endoscopic sessions cause of spleen or digestive interposition. In these situations,
had been performed before trans-fistulary drainage. In success- placement of an internal drain based on trans-fistulary double-
fully treated patients, a median number of 2 (range 1 – 6) endo- pigtail stent placement offers a viable alternative.
scopic sessions was necessary after trans-fistulary drainage (un- In the current series, the use of internal drainage was proposed as
til stent removal or stent migration was noted). first-line treatment but also as a rescue method in cases of failed
Statistical analysis evaluated whether factors such as the type of SEMS-based treatment, with no statistical difference in term of
bariatric surgery, treatment or diagnostic delays, or the use of clinical success between these two groups (85.7 % vs. 73.7 %,
trans-fistulary drainage as a primary or secondary treatment in- respectively; P = 0.672). The success rate was not influenced by
fluenced success rates. No significant predictor of success was any other predictive factor.
identified. Success rates were not influenced by the type of leak Delay in leak diagnosis or management is recognized to be a ma-
according to the Rosenthal classification [25] (P = 0.869). How- jor factor of treatment success [13, 25] when using luminal stent-
ever, the vast majority of patients had acute or early leaks. The ing (SEMS). In the current study, no difference in treatment suc-
delay between bariatric surgery and first endoscopic treatment cess rate was observed. This might suggest that the efficacy of
(P = 0.288) or the delay between bariatric surgery and trans-fistu- trans-fistular stenting is maintained even when treatment is
lary drainage (P = 0.399) also did not influence success rates. somewhat delayed.
Double-pigtail stents play a role in internal drainage that is sim-
ilar to their role in pseudocyst drainage. They keep the fistula
Discussion tract between the stomach lumen and the infected paragastric
! space open, while allowing the paragastric space to be cleaned
This study showed that trans-fistulary drainage was an effective and progressively reduced to a “virtual” cavity that is only occu-
and safe treatment of post-bariatric leaks in a selected group of pied by pigtail loops. Endoscopic internal drainage has already
patients with previous unsuccessful endoscopic modalities but been described in a number of small series of bariatric leakage
also as a first-line therapeutic modality in some patients. management, either as a complement to other endoscopic tech-

Bouchard Simon et al. Trans-fistulary endoscopic drainage for abdominal collections … Endoscopy
Original article

niques [11, 27, 28] or as an isolated procedure [22]. In a recent after an average of 31 days, with stent retrieval and opacification
paper, Donatelli et al. reported clinical success of internal drain- of any residual leak or collection using medium contrast. In cases
age in 50 patients out of 67 with post-sleeve gastrectomy leakage of patients with persistent extravasations, stents are reinserted
[23]. As in the current series, internal drainage was initiated in and patients are maintained on fasting until the next endoscopic
patients with or without external drainage depending on the follow-up [23]. In our series, good clinical success was obtained
severity of the initial clinical presentation. However, the authors with a much lighter protocol and early re-feeding. Multiple endo-
used this technique as a first-line approach in all patients. They scopic examinations and repeated manipulations of the healing
reported a very strict protocol of systematic endoscopic review zone may increase the risk of complications. Even if systematic
with stent exchange if healing of the fistula was not achieved. changes of stents may in theory promote healing by inducing
Patients underwent 2 – 16 procedures (mean 3.14) before final micro-traumatism, early re-feeding and a reduced number of
extraction of the stent. A majority of patients (55 out of 66) endoscopic procedures are significant advantages.
were maintained for at least 4 weeks (up to the first endoscopy Another potential advantage of endoscopic internal drainage,
follow-up examination) on prolonged fasting with enteral or par- compared with SEMS, is that it offers the opportunity to treat
enteral nutritional support depending on patient tolerance [23]. post-sleeve gastrectomy patients with unusual leakage locations.
In the current series, the time between stent insertion and the Even with a leak orifice situated more distally, up to the lower
start of permitted progressive oral feeding was much shorter. part of the sleeve suture, double-pigtail stents may be easily in-
Patients were generally instructed to resume an oral diet after serted. The number of cases treated to date is too limited to eval-

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CT confirmation of collection reduction, which was performed a uate the success rate in this particular setting but it seemed feasi-
median of 3 days after pigtail insertion. This early re-feeding did ble based on the current and previous series [23].
not seem to negatively impact success rates. This also suggests However, internal drainage is not a panacea. Treatment failure
that this treatment compares favorably with SEMS-based treat- occurred in 7 of the 33 patients included in the current study. Pa-
ment where, in successful cases, “watertightness” allowing oral tients with a unique and well-circumscribed collection are good
food intake is achieved in less than 1 week. candidates for this treatment approach, but complex leakages
At the beginning of our experience with this technique, we with trans-diaphragmatic or multiple fistulas and/or multiple
systematically confirmed the position of pigtail stents into the small collections are more likely to resist internal drainage, and
collection by CT scan and authorized re-feeding only after clinical thus to require surgical reintervention. It is also still uncertain
and radiological improvement. Currently, particularly in well-de- whether internal drainage is as effective as SEMS in very early
fined collections, good positioning of the stent is evaluated dur- leaks when a surgical drain is still in place, and where the SEMS-
ing the initial endoscopic procedure, and re-feeding is authorized based approach is still our first choice. The absence of an “orga-
within 24 – 48 hours following trans-fistulary drainage based nized” collection could be a disadvantage in these cases, although
only on biological and clinical improvement. the recent study by Donatelli et al. [23] has shown good results in
The median length of hospital stay in the study may appear long these patients.
(8 days), but its range (1 – 27 days) illustrates the complexity of In complex cases, further endoscopic techniques can be used to
certain cases. Patients without major sepsis, with a well circum- help achieve clinical success. Balloon dilation of the fistula tract
scribed collection that responds to drainage, and who resume an was performed in eight patients (mainly with an 8-mm balloon
oral diet, may be discharged quickly; however, other patients to allow insertion of two stents, and one dilation to 19 mm in sus-
with a complex post-bariatric history may need a longer hospital pected excluded stomach remnant) and one patient was treated
stay, even after infection control, owing to complex nutritional by endoscopic necrosectomy. Septotomy has been described in a
and medical issues. pilot series by a single team [29]; it was not used in the current
Insertion of double-pigtail stents for internal drainage offers series and although of potential interest, its place in the algo-
other advantages compared with SEMS treatment. In a significant rithm of tailored treatment has yet to be defined. In addition,
proportion of patients, after stent insertion and patient dis- even though in the current series no significant distal luminal
charge, no other endoscopic procedure will be required. Indeed, stricture was identified at the level of the gastrojejunal anasto-
after initial success of infection control, in 12 of 26 patients, pig- mosis or on the distal part of the sleeve, we do recommend bal-
tail stents migrated spontaneously during a median follow-up of loon stricture dilation if encountered, with balloon size adapted
287 days. On the contrary, when using partially covered SEMS, to local surgical luminal calibration (30 mm being the most fre-
two procedures are needed to retrieve the SEMS if one wants to quently used in post-sleeve situations in the absence of fibrotic
avoid complications related to removal. Our policy of stenting is stricture).
the use of partially covered stents with high longitudinal flexi- Adverse events associated with trans-fistulary drainage include
bility [10, 11, 13], which stay in place without the need for addi- suspected stent-induced discomfort or even bleeding, which re-
tional suturing and promote “watertightness” through tissue quire stent removal. The pigtail design limits direct gastric muco-
hyperplasia at both ends. These stents are removed through the sal trauma, but could favor local trauma at the level of the leak or
placement of a fully covered stent for 1 week to induce pressure in the perigastric structure. In two patients in the current study,
necrosis. We still prefer this technique to fully covered SEMS, bleeding was directly associated with a stent-related erosion. In
mainly because of better control of fluid passage along the exter- one case, major bleeding was due to spleen injury and required
nal part of the stent. surgical re-intervention. After this complication, we tried to
This difference in the number of required procedures has already avoid leaving stents in contact with the spleen parenchyma or
been reported in a series published by Pequignot et al. [22]. Eight splenic vessels. The position of stents just below the cardia and
patients treated with pigtail drains underwent a significantly post-bariatric anatomical modifications limiting gastric lumen
lower median number of endoscopic procedures compared with distension may explain a possible higher proportion of complica-
the 11 patients treated by SEMS insertion (3 vs. 5.5). Donatelli et tions associated with double-pigtail stent placement compared
al. suggested a systematic endoscopic follow-up examination with reports in drainage of other collections. Based on this ex-

Bouchard Simon et al. Trans-fistulary endoscopic drainage for abdominal collections … Endoscopy
Original article

perience, we currently use only 7-Fr double-pigtail stents, which References


induce less trauma than larger ones, and we avoid the use of 1 Yang L, Colditz GA. Prevalence of overweight and obesity in the United
straight stents. Our policy is now to remove the nonmigrated States, 2007 – 2012. JAMA Intern Med 2015; 175: 1412 – 1413
2 Ng M, Fleming T, Robinson M et al. Global, regional, and national prev-
stents after 3 months, based on CT confirmation of complete re- alence of overweight and obesity in children and adults during 1980 –
solution of the collection. 2013: a systematic analysis for the Global Burden of Disease Study
As with pseudocyst drainage, the internal drainage technique in 2013. Lancet 2014; 384: 766 – 781
leak management requires slightly different endoscopist exper- 3 Puzziferri N, Roshek TBIII, Mayou HG et al. Long-term follow-up after
bariatric surgery: a systematic review. JAMA 2014; 312: 934 – 942
tise compared with SEMS placement. Endotherapists should be
4 ASGE Standards of Practice Committee, Evans JA, Muthusamy VR et al.
familiar with pigtail insertion and ideally with EUS collection The role of endoscopy in the bariatric surgery patient. Gastrointest En-
puncture in cases where the leak orifice cannot be easily identi- dosc 2015; 81: 1063 – 1072
fied. The leak orifice may be identified endoscopically either by 5 Fernandez AZ Jr, DeMaria EJ, Tichansky DS et al. Experience with over
using a forward-viewing or side-viewing endoscope, depending 3000 open and laparoscopic bariatric procedures: multivariate analy-
sis of factors related to leak and resultant mortality. Surg Endosc 2004;
on surgical variation and leak location. In the current series, a
18: 193 – 197
side-viewing endoscope was used in only 18 % of the cases, which 6 Podnos YD, Jimenez JC, Wilson SE et al. Complications after laparoscopic
justifies the choice of a regular or therapeutic gastroscope to start gastric bypass: a review of 3464 cases. Arch Surg 2003; 138: 957 – 961
the procedure. CO2 insufflation is crucial in endoscopic manage- 7 Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak:
ment of these patients because of the potential communication a systematic analysis of 4,888 patients. Surg Endosc 2012; 26: 1509 –
1515

Downloaded by: Collections and Technical Services Department. Copyrighted material.


of the collection with the peritoneum.
8 Carrodeguas L, Szomstein S, Soto F et al. Management of gastrogastric
All of our patients were treated under general anesthesia with or- fistulas after divided Roux-en-Y gastric bypass surgery for morbid
otracheal intubation as per our local anesthesiology policy. It is obesity: analysis of 1,292 consecutive patients and review of litera-
reasonable to think that for patients in a stable clinical condition ture. Surg Obes Relat Dis 2005; 1: 467 – 474
9 Trastulli S, Desiderio J, Guarino S et al. Laparoscopic sleeve gastrectomy
and with a well circumscribed collection on CT, this type of pro-
compared with other bariatric surgical procedures: a systematic re-
cedure could be performed under conscious sedation. However, view of randomized trials. Surg Obes Relat Dis 2013; 9: 816 – 829
we would favor the liberal use of general anesthesia owing to 10 Eisendrath P, Cremer M, Himpens J et al. Endotherapy including tem-
the potential complexity of treatments. porary stenting of fistulas of the upper gastrointestinal tract after
If present, we suggest the early removal of any percutaneous laparoscopic bariatric surgery. Endoscopy 2007; 39: 625 – 630
11 Murino A, Arvanitakis M, Le Moine O et al. Effectiveness of endoscopic
drains if their only purpose is to drain the collection that would
management using self-expandable metal stents in a large cohort of
be drained by internal pigtails. Even if it is not clear that a percu- patients with post-bariatric leaks. Obes Surg 2015; 25: 1569 – 1576
taneous drain would impair the efficacy of internal drainage, 12 El Mourad H, Himpens J, Verhofstadt J. Stent treatment for fistula after
their removal provides a rapid clinical evaluation of leak resolu- obesity surgery: results in 47 consecutive patients. Surg Endosc 2013;
tion. 27: 808 – 816
13 Swinnen J, Eisendrath P, Rigaux J et al. Self-expandable metal stents for
Our group has recently published an algorithm for the manage-
the treatment of benign upper GI leaks and perforations. Gastrointest
ment of post-bariatric surgery leaks [30]. Tailoring treatment Endosc 2011; 73: 890 – 899
has become the rule in these patients, with the two major tech- 14 Voermans RP, Le Moine O, Von Renteln D et al. Efficacy of endoscopic
niques being luminal stenting (in combination with percu- closure of acute perforations of the gastrointestinal tract. Clin Gastro-
taneous drainage) and trans-fistular drainage, particularly useful enterol Hepatol 2012; 10: 603 – 608
15 Gomez V, Lukens FJ, Woodward TA. Closure of an iatrogenic bariatric
for delayed or refractory leaks without appropriate external gastric fistula with an over-the-scope clip. Surg Obes Relat Dis 2013;
drainage. Additional techniques such as fistula plugs, sleeve dila- 9: e31 – 33
tion (30 mm) or septal section might be considered according to 16 Toussaint E, Eisendrath P, Kwan V et al. Endoscopic treatment of post-
anatomical and clinical evolution. operative enterocutaneous fistulas after bariatric surgery with the
use of a fistula plug: report of five cases. Endoscopy 2009; 41: 560 –
In conclusion, endoscopic internal drainage of post-bariatric
563
leaks with double-pigtail stents offers an attractive alternative 17 Evans JA, Branch MS, Pryor AD et al. Endoscopic closure of a gastroje-
to SEMS-based treatment with a similar rate of success. The tech- junal anastomotic leak (with video). Gastrointest Endosc 2007; 66:
nique requires slightly different endoscopist expertise, but 1225 – 1226
should be considered as a treatment option in post-bariatic leak 18 Papavramidis ST, Eleftheriadis EE, Papavramidis TS et al. Endoscopic
management of gastrocutaneous fistula after bariatric surgery by
management. This option might be restricted to relatively well-
using a fibrin sealant. Gastrointest Endosc 2004; 59: 296 – 300
circumscribed collections without external drainage. Its exact 19 Fischer A, Thomusch O, Benz S et al. Nonoperative treatment of 15 be-
place as a first-line treatment in cases of fresh leaks with percu- nign esophageal perforations with self-expandable covered metal
taneous drainage should be well evaluated before being general- stents. Ann Thorac Surg 2006; 81: 467 – 472
ized. 20 El Hajj I, Imperiale T, Rex D et al. Treatment of esophageal leaks, fistulae,
and perforations with temporary stents: evaluation of efficacy, adverse
events, and factors associated with successful outcomes. Gastrointest
Competing interests: None Endosc 2014; 79: 589 – 598
21 Freeman RK, Ascioti AJ, Giannini T et al. Analysis of unsuccessful esoph-
ageal stent placements for esophageal perforation, fistula, or anasto-
motic leak. Ann Thorac Surg 2012; 94: 959 – 965
Acknowledgment
22 Pequignot A, Fuks D, Verhaeghe P et al. Is there a place for pigtail drains
!
in the management of gastric leaks after laparoscopic sleeve gastrec-
The authors thank Sandy Field, PhD, medical writer, for English- tomy? Obes Surg 2012; 22: 712 – 720
language editing of the manuscript. 23 Donatelli G, Dumont JL, Cereatti F et al. Treatment of leaks following
sleeve gastrectomy by endoscopic internal drainage (EID). Obes Surg
2015; 25: 1293 – 1301
24 Gupta T, Lemmers A, Tan D et al. EUS-guided transmural drainage of
postoperative collections. Gastrointest Endosc 2012; 76: 1259 – 1265

Bouchard Simon et al. Trans-fistulary endoscopic drainage for abdominal collections … Endoscopy
Original article

25 Rosenthal RJ, Diaz AA et al. International Sleeve Gastrectomy Expert 28 Donatelli G, Catheline JM, Dumont JL et al. Outcome of leaks after sleeve
Panel. International Sleeve Gastrectomy Expert Panel Consensus State- gastrectomy based on a new algorithm addressing leak size and gastric
ment: best practice guidelines based on experience of > 12,000 cases. stenosis. Obes Surg 2015; 25: 1258 – 1260
Surg Obes Relat Dis 2012; 8: 8 – 19 29 Baretta G, Campos J, Correia S et al. Bariatric postoperative fistula: a
26 Leenders BJ, Stronkhorst A, Smulders FJ et al. Removable and reposition- life-saving endoscopic procedure. Surg Endosc 2015; 29: 1714 – 1720
able covered metal self-expandable stents for leaks after upper gastro- 30 Eisendrath P, Devière J. Major complications of bariatric surgery:
intestinal surgery: experiences in a tertiary referral hospital. Surg En- endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol
dosc 2013; 27: 2751 – 2759 2015; 12: 701 – 710
27 Mercky P, Gonzalez JM, Aimore Bonin E et al. Usefulness of over-the-
scope clipping system for closing digestive fistulas. Dig Endosc 2015;
27: 18 – 24

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