1. 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

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

3. 2004.10.13. 2nd surgery Left Subphrenic abscess. Open Laparotomy
Lavage and drainage
Suture of the leak
Omental patch
Feeding jejunostomy.
Splenectomy
: Left chest empiema. Drainage. No leak in CT scan
: Leak shown at the EGJ. Cardias stenosis

4. 2004.11.21: Transfer to University Hospital
Infected wound
Left upper quadrnat drain
: ICU with pneumonia GI shows a 10 mm. EGJ fistula

5. rd operation
Cholecystectomy RNY to EGJ ICU until months Discharged 4 months stay

6. 4th operation 2006. June. 1 year later
4th operation June. 1 year later Ventral hernia repaired with Prolene mesh October: Left percutaneous sub-phrenic abscess drainage

7. 2008 2008. April: Admitted for medical management of a fistula.
: Removable stent
: 5th operation. Re-lapaparotomy. Fistula was localized and sutured.
: The fistula re-opens with low output
: Left sub-phrenic abscess . Radiological drainage.
ICI and septic shock. Mechanical ventilation

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

9. 2009 2009.01.23: Colonic fistula. 7th operation.
Transverse colostomy and closure of the distal stump
: Leak at EGJ
: ICU. Septic shock. Wernicke. Thrombosis of left cervical veins Mechanical ventilation. Malnutrition. TPN.
: EDT. Endoscopic occlusion with cyanoacrylate.
Placement of clips in fistula plus
Biodegradable prosthesis 6 cm. in diameter.

10. 2010 2010.05.17: 8th operation. Under sedation
Opening of the fistula hole in left chest cavity, limited thoracotomy and cleansing.

11. 2012
: 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

13. Stents
2006 IFSO meeting

14. RNY Limb

15. 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

16. Septal Ocluder

17. 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!!!!