Chronic Sleeve-Forming Gastrectomy fistula.

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Presentation transcript:

Chronic Sleeve-Forming Gastrectomy fistula. Session: Grab the bull by the horns! Resolutely dealing with the problem! Chronic Sleeve-Forming Gastrectomy fistula. Eleven years and nine operations Aniceto Baltasar. Alcoy. Clínica San Jorge. Alcoy Juan Carlos Ruiz & Alberto Hernández. Hospital de Getafe Eduardo Domínguez-Adame. Hospital Macarena. Sevilla

Clinical case 34 years-old female IBMI-40 No co-morbidities 2004.10.09. Surgery at a Private institution SFG + RNY Cholecysto-jejunostomy Hollian & Lavorato & Micheletto operation Today abandoned!

2004.10.13. 2nd surgery Left Subphrenic abscess. Open Laparotomy Lavage and drainage Suture of the leak Omental patch Feeding jejunostomy. Splenectomy 2004.10.18: Left chest empiema. Drainage. No leak in CT scan 2004.10.25: Leak shown at the EGJ. Cardias stenosis

2004.11.21: Transfer to University Hospital Infected wound Left upper quadrnat drain 2004.12.19: ICU with pneumonia GI shows a 10 mm. EGJ fistula

2004.10.27. 3rd operation Cholecystectomy RNY to EGJ ICU until 2005.03.11 3 months 2005.04.02 Discharged 4 months stay

4th operation 2006. June. 1 year later 4th operation 2006. June. 1 year later Ventral hernia repaired with Prolene mesh. 2007. October: Left percutaneous sub-phrenic abscess drainage

2008 2008. April: Admitted for medical management of a fistula. 2008.05.27: Removable stent 2008.06.25: 5th operation. Re-lapaparotomy. Fistula was localized and sutured. 2008.08.07: The fistula re-opens with low output 2008.09.24: Left sub-phrenic abscess . Radiological drainage. 2008.10.28 ICI and septic shock. Mechanical ventilation

2008.12.12. 6th operation EGJ resection End-to-Side Esophago-gastric anastomosis Transverse colon resection and End-to-End 2008.12.23 Fistula re-opens again

2009 2009.01.23: Colonic fistula. 7th operation. Transverse colostomy and closure of the distal stump 2009.03.17: Leak at EGJ 2009.04.03: ICU. Septic shock. Wernicke. Thrombosis of left cervical veins. Mechanical ventilation. Malnutrition. TPN. 2009.04.13: EDT. Endoscopic occlusion with cyanoacrylate. Placement of clips in fistula plus Biodegradable prosthesis 6 cm. in diameter.

2010 2010.05.17: 8th operation. Under sedation Opening of the fistula hole in left chest cavity, limited thoracotomy and cleansing.

2012 2012.02.07: 9th operation Resection of segment of small intestine fistula. Supra-mesocolic compartment blockage allowing not access to EGJ Colon and small bowel restoration Fistula is still present Late readmission for PCM treated with TPN & NJ Feeding

Stents 2006 IFSO meeting

RNY Limb

EDT (Endo-diagnotic therapy) OVESCO: Over the scope clips.A promising system for endoscopic closure of the perforations of the digestive tract IMC-17,6 EDT. Glues (Glubran), Coils, Stents, clips, POSE, Suturing Drains. Naso-jejunal feeding Septal occluder

Septal Ocluder

What is behind a chronic leak? Stenosis of the sleeve Mal-rotation of the sleeve Poor emptying Thick severely inflammed gastric and perigastric tissues Total gastrectomy may be the best treatment…. But…in all cases EDT therapy should be tried first So, who say “Grab the bull by the horns” All opinions in this case management are aceptable!!! Grab the bull by the horns!!!!