bariatric surgery | Acta Medica Marisiensis

Case Report: Endoscopic Management of Sleeve Gastrectomy Fistula

Roşu Alexandra Floriana^1*, Ferreira Carlos Noronha², Ribeiro Luis Carrilho², Velosa José², Zlatian Ovidiu Mircea³

1 Gastroenterology Department, County Clinical Emergency Hospital, Craiova, Romania
2 Gastroenterology and Hepatology Department, University Hospital Santa Maria, Lisbon, Portugal
3 Microbiology department, University of Medicine and Pharmacy of Craiova, Romania

DOI: 10.1515/amma-2016-0049

Background. Morbid obesity is an important cause of morbidity and mortality. Bariatric surgery is the best option to manage obesity. Vertical gastrectomy is safe and effective but sometimes complicate with hemorrhage, fistulas and stenosis. Fistulas can be solved by conventional surgery or interventional endoscopy.
Case presentation. We describe a morbidly obese patient with vertical gastrectomy who developed complications after surgery. Immediately after surgery the patient developed sepsis. Upper gastrointestinal endoscopy excluded fistula. One month later a peri-gastric abscess developed due to a fistula orifice in the distal esophagus, treated with argon plasma and two double pigtail plastic stents placed endoscopically to drain the abscess. The stents were removed two weeks later and was placed a covered metallic stent in the distal esophagus. Six weeks later the metallic stent was removed and the orifice closed. Four months later the patient developed sepsis. Computer tomography revealed a subdiaphragmatic abscess and endoscopy revealed a 2 mm fistula orifice at the previous site, treated with argon plasma and two trough-the-scope clips that closed it. There were no further incidents after two years of follow-up.
Conclusions. Early diagnosis and endoscopic approach can resolve these complications without the morbidity and increased mortality risk of surgical re-interventions.

Obesity is a disease with severe health consequences and increased risk of mortality. The most commonly used criteria to assess the presence and the severity of obesity are body mass index, waist circumference, waist-to-height ratio and the presence of the health conditions caused or worsened by obesity. Worldwide obesity has more than doubled in the last 4 decades. Obesity is the second of the leading preventable causes of death worldwide (after smoking). Obesity has a plurifactorial pathogenesis. The central perturbation consists in the imbalance between calories intake and calories consumption (by inappropriate diet and sedentary lifestyle). Identification of all the ethiological factors is important for treatment and prophylaxis. Weight loss benefits are multiple and important: improvement in glicemic control and in plasma lipid levels, blood presure control, obstructiv sleep apneea reduction, improvement in management of daily activities and profesional performances, increase quality of life, reduction in mortality. Overweight or obese patient will complete a diagnostic and a treatment program. Treatment of obesity claims a targeted multidimensional therapy: weight and lifestyle management, diet, sustained physical activity in daily life, exercise, decrease life stressors, smoking cessation, drug therapy, bariatric surgery psichological, familial and social suport. Weight loss program must be carefully planned, adapted to the patient’s abilities and comorbidities and supervised by a nutritionist and a physiotherapist.