Surg Endosc DOI 10.1007/s00464-014-3424-y

and Other Interventional Techniques

Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post–sleeve gastrectomy fistula Elie Chouillard • Elias Chahine • Naim Schoucair Antoine Younan • Mohammad Al Jarallah • Alain Fajardy • Rene´-Louis Vitte • Jean Biagini



Received: 29 June 2013 / Accepted: 1 January 2014 Ó Springer Science+Business Media New York 2014

Abstract Background Sleeve gastrectomy (SG) is currently the most common bariatric procedure in France. It achieves both adequate excess weight loss and significant reduction of comorbidities. However, leak is still the most common complication after SG. Nevertheless, its risk of occurrence is \3 % in specialized centers. Its management is difficult, long, and challenging. Although the procedure is commonly endoscopic and nonoperative, the management of post-SG fistulas could sometimes be surgical, including peritoneal lavage, abscess drainage, disrupted staple line suturing, resleeve, gastric bypass, or total gastrectomy. Roux-en-Y fistulojejunostomy (RYFJ) has been described as a salvage option. In this study, we report the early results of RYFJ for post-SG fistula, emphasizing indications, operative technique, and short-term outcome.

On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), France Presented at the SAGES 2013 Annual Meeting, April 17- April 20, 2013, Baltimore, MD E. Chouillard (&)  E. Chahine  N. Schoucair Division of Bariatric Surgery, Department of Surgery, Poissy/ Saint-Germain Medical Center, 10 rue du Champ Gaillard, 78300 Poissy, France e-mail: [email protected] A. Younan Department of General Surgery, Lebanese-Canadian Hospital, Beirut, Lebanon M. A. Jarallah Department of Bariatric Surgery, Al-Jarrallah German Specialized Center, Kuwait City, Kuwait

Methods Between January 2007 and December 2012, we treated 62 patients with post-SG fistula. Before surgery, intra-abdominal or thoracic abscesses or collections were either excluded or treated by computed tomographic scan– guided drainage or even surgery. Endoscopic stenting was then attempted. After optimization of the nutritional status in case of failure of endoscopic measures, some of the patients underwent RYFJ. Results Between January 2007 and December 2012, a total of 21 patients (16 women and 5 men) had RYFJ for post-SG fistula. Mean age was 47 years (range, 22–59 years). Procedures were performed laparoscopically in all but 3 cases. The rate of secondary conversion to laparotomy was 11.1 %. The was no mortality. The postoperative morbidity rate was less than 5 %. The rate of fistula control was eventually 100 %. Conclusions RYFJ is a safe and feasible salvage procedure for the treatment of patients with post-SG fistula. Longer outcome analysis is, however, needed especially regarding the physiological and metabolic behavior of the procedure. Keywords Bariatric  Complication  Fistula  Gastrectomy  Laparoscopy  Obesity  Sleeve  Surgery A. Fajardy Department of Surgery, Unit of Critical Care and Nutrition, Poissy/Saint-Germain Medical Center, Poissy, France R.-L. Vitte Division of Surgical Endoscopy, Department of Gastroenteroplogy and Hepatology, Poissy/Saint-Germain Medical Center, Poissy, France J. Biagini Department of General and Digestive Surgery, Saint-Joseph Medical Center, Beirut, Lebanon

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Sleeve gastrectomy (SG) is a commonly used procedure used in patients with morbid obesity. Initially proposed in the superobese, as a first step [1] before a more complex procedure (i.e., duodenal switch), SG has now become a valid primary procedure [2, 3] that may be used in almost any patient with morbid obesity. Leak is still the most problematic complication after SG, occurring in upto 7 % of cases in some major series [4]. The management of post-SG fistula is long and cumbersome, especially for leaks located at the esophagogastric junction. In patients with early fistulas presenting with hemodynamic instability, reoperation and repair could be indicated [5]. On the other hand, stable patients with acute fistulas could be managed conservatively (i.e., percutaneous drainage, parenteral or enteral nutrition, proton pump inhibitors, and broad-spectrum antibiotics). Finally, if the fistula persists, different options have been proposed, including radioguided collection drainage and endoscopy-based treatment, including stents, among other options [6, 7]. The philosophy is to create a temporary bypass of the fistula until healing and closure occur spontaneously. The success rate of such conservative management is between 40 and 70 % [4, 8]. Patients with persistent fistula are candidates for salvage surgery, including conversion to gastric bypass, or total gastrectomy [7, 9, 10]. In this study, we retrospectively reviewed our series of patients who underwent Roux-en-Y fistulojejunostomy (RYFJ) as a salvage procedure for post-SG fistulas who are reluctant to undergo nonoperative treatment.

unstable patients, surgery may be required, mainly to control sepsis and perform peritoneal lavage. Regarding the direct management of the leak itself, options included simple suturing, resleeving to remove the disrupted area, applying an omental patch or fibrin sealants, or even performing early RYFJ. However, starting in 2010, the sole option implemented in cases of fistula in patients 3 months or less after surgery has become peritoneal lavage and drainage. No additional action was undertaken on the leak itself during this early period. In fistulas that occurred more than 3 months after surgery, initial management was almost exclusively conservative and was based on nutritional and general measures (i.e., enteral or parenteral nutrition, antibiotics, proton pump inhibitors, psychological support) and endoscopic stenting. Any collection, either thoracic or abdominal, is drained under computed tomographic (CT) scan guidance. Endoscopy is the cornerstone of management of these patients, using fully covered wall flex stent. This theoretically allows oral intake to be resumed. The stent is removed 4 or 5 weeks later. Healing is assessed by CT scan with intravenous and oral contrast. In case of persistent fistula, a second attempt with flex stent could be proposed. If nonoperative management is a failure, or in any patient with a fistula that occurred[3 months after surgery, surgical management with RYFJ was proposed. This was performed after nutritional status optimization (i.e., albumin [ 35 g/dL) and sepsis control (i.e., white blood cell count \ 10,000/mm3; C-reactive protein \ 50 g/L). Technique

Patients and methods Patients The charts of all patients treated for post-SG fistula located at the esophagogastric junction between January 2007 and December 2012 were reviewed. Forty-six patients were treated in Poissy/Saint-Germain Medical Center (France), 6 patients in the Lebanese–Canadian Hospital (Lebanon), 6 patients in Saint-Joseph Medical Center (Lebanon), and 4 patients in Al-Jarrallah German Specialized Center (Kuwait). The principles of management were the same according to the guidelines of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS). The management algorithm is dependent on the interval from SG and the general condition of the patient. In hemodynamically stable patients with an interval from primary surgery of 3 months or less, management is usually conservative, including mainly percutaneous drainage of septic collections, enteral or parenteral nutrition, and endoscopic stenting. However, in hemodynamically

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The patient was placed in the lithotomy position. Laparoscopy was attempted in all but 3 patients, even in patients with previous laparotomy. The operator was positioned in between the legs, with the first assistant to the left side and the second assistant to the right. The monitor was placed toward the head of the patient on the left side. Under general anesthesia, a 30-degree laparoscope was introduced through a 12-mm incision located 1.5 cm to the left side of the midline and 18 cm from the xiphoid appendix. Three or four additional trocars, either 5 or 12 mm in diameter, were inserted in the upper quadrants, the epigastric area, and the left lateral quadrant, respectively. The dissection always began with the freeing of the left liver lobe, which was usually quite affected by the inflammatory process beneath (Fig. 1). Complete dissection of the sleeved stomach was performed. In case of previous percutaneous drainage, the drain tract could be used in order to reach the fistula, avoiding inadvertent tissue damage. We preferentially used previously nondissected planes, including the pars flaccida, the right crux,

Surg Endosc

Fig. 1 Operative view of a patient operated for post–sleeve gastrectomy fistula. Dense adhesions are located between inferior aspect of left liver lobe and stomach

and the lesser sac (Fig. 2). Every effort was made in order to avoid damaging the remaining gastric blood supply (i.e., the right and left gastric arteries). Complete dissection of the esophagogastric junction with mobilization of the lower third of the esophagus was mandatory (Fig. 3). This enabled tension-free anastomosis between the fistula site and the jejunum, especially in very high fistulas. In case of associated diaphragmatic defects, closure with interrupted nonabsorbable sutures was performed. Debridement of the fistula margins is important in order to perform the fistulojejunostomy using well-vascularized, healthy tissue (Fig. 4). The jejunum was then divided 60 cm from the Treitz angle and mobilized through the transverse mesocolon. Fistulojejunostomy was performed using 00 or 000 PDS running sutures (Fig. 5). Jejunojejunostomy was performed using automatic stapling (EndoGIA, Covidien France, Elancourt, France).

Fig. 3 Operative view of a patient operated for post–sleeve gastrectomy fistula. Hiatal region is being fully dissected above level of fistula at angle of His

The mesocolon defect was closed around the Roux limb with nonabsorbable 00 sutures. Percutaneous closed drainage of the hiatal area was performed. A nasogastric tube with mild negative pressure was left in place for 4 days. In the postoperative period, patients were kept on parenteral nutrition for 7 days. Day 8 thoraco-abdominal CT scan with oral contrast fluid was performed before resuming oral intake. The patient was then authorized to leave the hospital with protein pump inhibitors for 6 months. Additional metabolic or vitamin support was prescribed if required according to the results of specific blood tests. The patients were reexamined at postoperative day 30 with a CT scan to exclude residual fluid collection or fistula. Long-term multidisciplinary follow-up was that of any patient who had undergone bariatric surgery. The patient was evaluated clinically and biologically every 3 months for 2 years and then every 6 months for 3 years. Blood tests include liver function assessment, vitamin status (B1, B6, B9, B12, D, K), electrolytes, lipids, and thyroid and parathyroid function parameters. In this report, we discuss the early outcome of RYFJ. A longer outcome assessment, including endoscopy aspects, radiologic behavior of the procedure, and the procedure’s metabolic consequences, is currently underway and will be reported in the future.

Results Fig. 2 Operative view of a patient operated for post–sleeve gastrectomy fistula. Dissection of esophagogastric junction starts at level of right crus to avoid previously dissected plans

Between January 2007 and December 2012, we managed 62 patients with post-SG fistula. Of these, 56 patients (90 %) were referred from another center. Because of the

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Fig. 4 Operative view of a patient operated for post–sleeve gastrectomy fistula. Edges of angle of His fistula have been debrided with well-vascularized mucosa

Fig. 5 Operative view of a patient operated for post–sleeve gastrectomy fistula. Side-to-side fistulojejunostomy is performed using 00 running PDS sutures

heterogeneity of the referral origin, it was difficult to establish an accurate and complete analysis of the technical aspects of the procedure (i.e., stapling device, bougie size, buttressing materiel, oversewing). Of these patients, 49 (79.1 %) presented at a less than 3-month interval from SG. The remaining 13 patients (20.9 %) were beyond a 3-month interval from primary SG, including 10 patients with subdiaphragmatic fistula and 3 patients with lower thoracic fistula tract. In these 13 patients, no attempt at endoscopic treatment was performed. The median duration of the fistula was 26 months (range, 4–133 months). In four patients, abdominal (n = 3) or thoracic (n = 2) drainage of collections was performed before RYFJ. One patient had open left lower pulmonary lobe resection for gastrobronchial fistula. Among 49 patients who presented with fistulas at less than 3 months after SG, the median interval was 16 days

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(range, 1–88 days). All but one of these fistulas were subdiaphragmatic. Of these, 10 patients had early reoperation for sepsis, including 8 by laparoscopy and 2 by laparotomy. All patients had peritoneal lavage and drainage. Additionally, one patient had fistula suturing and another resleeve gastrectomy. Endoscopic treatment was performed in 41 patients, including 38 patients who had stents. Additionally, fibrin glue injection and transoral drainage of collections were performed in 9 and 7 patients, respectively. Three patients who did not have stenting had only transoral drainage of the fistula. Three of 38 patients (7.9 %) could not tolerate their stents, leading to early removal as a result of nausea, epigastric pain, and hypersalivation. In the remaining 35 patients, stents were removed after 4–6 weeks. Limited migration, either toward the pylorus or the esophagus, was common (11 patients, 31.4 %). However, in the majority of patients, the fistula origin was still covered by the stent. In 1 patient (2.6 %), distal migration to the duodenum lead to acute ulcer and hemorrhage originating from the gastroduodenal artery. Urgent removal of the stent and endovascular embolization of the gastroduodenal artery were performed. The algorithm for patient management is summarized in Table 1. The radiological success rate of the first endoscopic stenting, as defined by the absence of extravasation of contrast fluid upon control CT scan, was 76.4 % (26 of 34 patients). Of these 8 patients, 1 had RYFJ without further endoscopic attempts at treatment. In the remaining 7, a second stenting was performed with success in only 2 patients. There were 16 women and 5 men. Mean age was 47 years (range, 22–59 years). Preoperative body mass index was 44 kg/m2 (range, 36–54 kg/m2). Just before RYFJ, residual body mass index was 34 kg/m2 (range, 22–49 kg/m2). Laparoscopy was attempted in 18 patients, while 3 patients had open surgery. Secondary conversion to laparotomy occurred in 2 patients (11.1 %). The causes of conversion were poor exposure and bleeding. The left lobe of the liver was the major cause of poor exposure. The median operative time was 216 min (range, 124–431 min). Besides two limited bleedings, no major operative incident was encountered. One patient was transfused (4.7 %). No splenectomy had to be performed. The methylene blue leak test was always negative. The mortality rate was zero. The postoperative rate of complications was 4.7 %; 1 patient had pneumonia. No hemorrhage, no surgical site infection, and no residual fistula were encountered. The radiological success rate of the fistula healing was 100 % as assessed by control CT scan at 1 week or 1 month after surgery. Liquid oral diet was successfully introduced on postoperative day 8 in all but 1 patient, who had vomiting. The median length of hospital stay was 11 days (range, 8–19 days).

Surg Endosc Table 1 Algorithm summarizing pathway of patients undergoing RYFJ

a

62 patients with post SG fistulas

49 patients < 3 months fistulas 16 days (range 1-88)

13 patients > 3 months fistulas 26 months (range 4133)

Early reoperation

NO (39)

YES (10)

36/39

Resleeve 1

Suturing 1

Lavage/Drainage 8 5/8

3/8 HEALING 5 Stent + Glue or transoral drainage 13

HEALING 3patients 3/16

HEALING 3 (3/39)

Endoscopic treatment 41

Transoral drainage alone 3

STENTING 13 patients 13/16

35 patients stents removed after 4 to 6 weeks 30 patients: success and control of fistulas (after 1 or 2 stentings)

Stent alone 25

Endoscopic stenting 13 + 25 = 38

3 patients did not tolerate

13 + 3 +5 = 21 patients RYFJ

5 patients: failure of fistula control after 1 or 2 stentings (+ 1 patient with stentrelated bleeding)

RYFJ Roux-en-Y fistulojejunostomy a

Twenty-one patients underwent RYFJ of 62 patients who presented with fistula at the esophagogastric junction after sleeve gastrectomy. Thirteen patients presented with fistulas more than 3 months old and underwent RYFJ without attempting other treatments. However, 49 patients with fistulas less than 3 months old underwent multimodal treatment, including surgical drainage and endoscopic approach with or without stenting. Eight additional patients eventually had RYFJ after this more conservative approach failed

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All patients were examined on postoperative day 30. No morbidity was disclosed.

Discussion SG has been adopted by a large number of surgeons, mainly as a result of its apparent simplicity and reproducibility. Compared to roux-en-y gastric bypass or duodenal switch, SG is associated with less overall morbidity and mortality. Although it occurs in less than 3 % of patients in major series [5, 8, 11], suture line dehiscence dramatically increases morbidity and hospital stay duration in patients who undergo SG. Management of such leaks is difficult and is best performed, as in our series, by a multidisciplinary specialized team. Most leaks occur in the proximal third of the stomach, close to the gastroesophageal junction. Burgos et al. [5] reported that 85.7 % of the leaks in their study population occurred in the proximal third and only 14.3 % in the distal third. In our experience, all leaks that did not readily respond to conservative management were located at the gastroesophageal junction. Such fistulas are more likely to occur in SG patients with distal stenosis, resulting in difficulties in gastric emptying [12]. High intraluminal pressure and low compliance of the gastric tube may be the main cause of leak, or even the primum movens in its genesis [7]. This is why fistulojejunostomy seems to be, pathophysiologically, a relevant solution: it bypasses both difficulties (gastric lack of compliance and endoluminal high pressure). However, additional factors are most probably implicated in the occurrence of fistulas, including impaired suture line healing, poor blood flow, infection, and poor oxygenation with subsequent ischemia. The most important factor in reducing the incidence of post-SG fistulas is prevention. Relevant steps include gentle tissue handling, optimal use of endostaplers, prevention of distal stenosis, and adequate hemostasis without damaging tissues with electrocautery [5]. The use of an absorbable polymer membrane (Seamguard, Gore, Flagstaff, AZ, USA) to strengthen the suture line [13] was not found to significantly lower the incidence of leaks. However, the use of a bougie of 40F or more should be considered a major factor in decreasing the risk of fistula [13]. Other proposed measures [14–16] include seroserous suture, simple oversewing of the suture line, fibrin sealants, omentoplasty, and the adjunction of miscellaneous hemostatic agents. When using endostaples, it is advisable to begin tissue compression carefully and sustain this position long enough to allow the tissue fluids to smoothly exit, without disrupting the neighboring muscle layers [17]. We advise waiting for 20–30 s before beginning stapling the already crushed tissue.

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Our patients underwent a heterogeneous panel of techniques to treat SG. They came from six different countries and underwent at least as many surgical techniques. This is why it seems difficult to draw any conclusions regarding the possible factors that led to the leak. However, the management was eventually homogeneous and was implemented by the same multidisciplinary team. Our approach to the management of patients with post-SG fistulas has evolved after 10 years of experience with this technique. Our first SG was performed in 2002. Starting in 2008, our center was designated as a referral site for the management of complications of bariatric surgery, either for patients operated in the Paris area or for patients who came from other countries. A multidisciplinary approach is always indicated, with decisions taken jointly by the surgeon, the gastroenterologist, the radiologist, and the critical care specialist. The patient is closely monitored by a team of psychologists who specialize in obesity management. Depression and suicidal ideation are common among these patients, many of them who have been treated for years, with long cumulative hospital stays. As we stated previously, management is mainly nonoperative in fistulas less than 3 months old for two reasons: the significant success rate of endoscopic management and the high failure rate of surgery, which is usually performed on inflammatory and septic tissues. Of course, patients with hemodynamic instability require reintervention, as do those with complicated fistulas or with signs of sepsis that cannot be controlled by using conservative treatment [18]. In our hands, the rate of success of endoscopic management is [70 % with options including biological glues [8, 19], transoral abscess drainage, and flexible coated stents [5, 6, 20–23]. Such an approach enabled us to treat patients with fistulas less than 3 months old, mainly at home with very short day-care hospital stays to ensure control. It is useless and irrelevant to go beyond two stent insertions because the failure rate is so high. This may be because the fibrosis of the fistula tract rendering its contraction and obturation mot probable in [3-month fistulas. Tolerance to stents is variable. Nausea, vomiting, drooling, early satiety, and retrosternal discomfort are the most common symptoms after their placement; they tend to disappear after a few days [8]. Psychological preparation of the patients to the discomfort of the stent could increase the chances of tolerance. By applying such an approach, the rate of acceptance of the stent was more than 92 %. However, the risk of migration is significant, especially toward the esophagus. Although relatively less common, distal migration toward the duodenum may be more cumbersome and may carry the risk of hemorrhage or gastric outlet obstruction. We also recommend removing the stent after 4–5 weeks to avoid incrustation resulting from regenerating tissue. This is shorter than the 6–8 weeks recommended in the literature [20].

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Patients who do not respond to endoscopic management and those with recurrent fistulas or fistulas of more than 3 months’ duration have usually been candidates for conversion to Roux-en-Y gastric bypass or total gastrectomy [7, 9, 10]. Roux-en-Y gastric bypass could be an option in case of possible gastric remnant. However, limitations include the risk of leaving the fistula tract in very high localization and the metabolic consequences of gastric bypass. Total gastrectomy is associated to a relatively high risk of complications related to the esophagojejunal anastomosis. Moreover, the long-term nutritional consequences are cumbersome, with weight loss and anemia, as well as the need to readjust the volume and frequencies of meals. We believe that RYFJ is the best option because it controls the fistula site in all cases, may preserve the chance of maintaining the SG preferential pathway in the future with bypass-like metabolic consequences, and avoid the complications of an anastomosis performed on an ill-vascularized esophagus. The use of a Roux limb type for the anastomosis aims to allow less tension on the gastrojejunal anastomosis while avoiding the risk of biliary reflux. We hope to soon report on the longer-term outcome of RYFJ, emphasizing the morphological and physiological behavior of the upper digestive tract in this setting.

Disclosures Elie Chouillard, Elias Chahine, Naim Schoucair, Antoine Younan, Mohammad Al Jarallah, Alain Fajardy, Rene´-Louis Vitte, and Jean Biagini have no conflicts of interest or financial ties to disclose.

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Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post-sleeve gastrectomy fistula.

Sleeve gastrectomy (SG) is currently the most common bariatric procedure in France. It achieves both adequate excess weight loss and significant reduc...
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