Baretta Giorgio, Campos Josemberg, Correia Sércio, Alhinho Helga, Marchesini João Batista, Lima João Henrique, Neto Manoel Galvão
Federal University of Parana, Curitiba, Parana, Brazil,
Surg Endosc. 2015 Jul;29(7):1714-20. doi: 10.1007/s00464-014-3869-z. Epub 2014 Oct 8.
Gastric fistula after bariatric surgery has high morbi-mortality, and treatment is a challenge due to persistent abscess and/or distal stenosis. The present study evaluated the efficacy and safety of stricturotomy/internal drainage, a novel endoscopic procedure that can avoid re-operation and allow early oral feeding.
This prospective, non-randomized study, with no control or sham group, included 27 patients (74.07% were female), approved by the local IRB, who underwent the following bariatric surgeries: Roux-en-Y gastric bypass (RYGB; n = 14, 51.85%), laparoscopic sleeve gastrectomy (LSG; n = 9, 33.33%) and duodenal switch (DS; n = 4, 14.81%). The patients presented with gastric fistulas which were treated by internal drainage/stricturotomy. The mean patient age was 42.67 years, and the mean pre-operative BMI was 40.69 kg/m(2). Balloon dilation was performed if distal stenosis and/or axis deviation was present. The first endoscopic procedure was applied on the 15th day after RYGB and the 30th day after LSG and DS.
All patients presented with His angle fistula. Eight patients (57.1%) had stenosis of the anastomosis after RYGB and were treated with balloon dilatation (20 mm). The patients submitted to LSG and DS had stenosis at the angularis incisure and were treated with achalasia balloon dilation (30 mm). The number of endoscopic sessions for stricturotomy ranged from 1 to 6. Two patients experienced bleeding after dilation, and one had perforation. The mean time to achieve fistula closure was 18.11 days (range, 1-72 days) without mortality. All the fistulas closed.
This novel endoscopic procedure is safe, feasible, and effective, avoiding re-operation, allowing early oral feeding and discharge.
减肥手术后胃瘘具有较高的病残率和死亡率，由于持续存在脓肿和/或远端狭窄，治疗颇具挑战性。本研究评估了狭窄切开术/内引流术的疗效和安全性，这是一种新型内镜手术，可避免再次手术并允许早期经口进食。
这项前瞻性、非随机研究未设对照组或假手术组，纳入了27例患者（74.07%为女性），经当地机构审查委员会批准，这些患者接受了以下减肥手术：Roux-en-Y胃旁路术（RYGB；n = 14，51.85%）、腹腔镜袖状胃切除术（LSG；n = 9，33.33%）和十二指肠转位术（DS；n = 4，14.81%）。患者出现胃瘘后接受内引流/狭窄切开术治疗。患者的平均年龄为42.67岁，术前平均体重指数为40.69kg/m²。如果存在远端狭窄和/或轴偏移，则进行球囊扩张。首次内镜手术在RYGB术后第15天以及LSG和DS术后第30天进行。
所有患者均为贲门角瘘。8例患者（57.1%）在RYGB术后出现吻合口狭窄，并接受了球囊扩张（20mm）治疗。接受LSG和DS手术的患者在角切迹处出现狭窄，并接受了贲门失弛缓症球囊扩张（30mm）治疗。狭窄切开术的内镜治疗次数为1至6次。2例患者在扩张后出现出血，1例发生穿孔。实现瘘口闭合的平均时间为18.11天（范围为1至72天），无死亡病例。所有瘘口均闭合。
这种新型内镜手术安全、可行且有效，避免了再次手术，允许早期经口进食和出院。
