A 45 year old woman with a BMI of 45 with Type2 DM underwent Lap sleeve 7months ago. She presented two weeks later with sepsis due to a leak. She was treated initially with NBM,TPN and Antibiotics. Soon after stabilizing ,she had an endoscopy and deployment of long wallstent from the esophagus in to the duodenum. She recovered well and was discharged. She was reamitted two months later with sepsis and left abdominal wall abscess. The abscess was drained and a diag lap and feeding jejunostomy was done. Her recovery was little slow but satisfactory. The stent was removed two months later. 7 months after primary surgery, she presented again with sepsis and a large left flank abscess. Contrast cect showed a leak at the remanant fundus of the stomach away from the Gastroesophageal jn. A pig tail catheter drain was placed in the abscess cavity which drained 360 mls. of pus. Presently she is on NBM,IV Antibiotis and TPN.
A year ago I had a similar case of chronic fistula after sleeve. After several attempts ( for ten moths) with both stent than with metal clips, I decided to go to surgery. In open surgery, I solved by converting to RYGB, using the remnant fundus like a gastric pouch, with no gastric resection to avoid further area of possible leak. The patient is going well since one year.
I agree with Stefano. We also managed a gastric fistula by converting the sleeve to RYGBP. We were able to do it laparoscopically. We presume that a RYGBP has less intra luminal pressure while a sleeve, being a hollow tube has a high pressure which makes fistulas difficult to manage with stents or other conservative measures.
Chronic Fistulas are difficult to treat but possible, first you should reach a situation that the area behind the tract is fully debrided - I often do a number of endoscopies with opening of the tract to the stomach and most of them heal in time. You need patience and good team work with a bariatric endoscopist
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