Evaluation of Endoscopic Internal Drainage By Using Double Pigtail Stent Insertion As a Management Modality in Patients With Post-Sleeve Gastrectomy Leakage and Fistula Formation

Abstract

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a widely used procedure in treating morbid obesity. The LSG can lead to complications some of which can be fatal as leakage. Several strategies can be used to treat leakage after LSG as conservative management, endoscopic stenting, exploration and drainage with feeding jejunostomy or conversion to Roux en Y bypass with or without a proximal gastrectomy.

Patients and Methods: In this study we tried to evaluate the use of double pig tail inserted by endoscope as a procedure of internal drainage in the management of leakage and fistula formation after laparoscopic sleeve gastrectomy in attempt for fistula healing without the need for surgical intervention. 436 primary sleeve gastrectomies were performed with 23 cases (5.27%) of leakage meeting the inclusion criteria.

Results: The mean time for presentation with leakage was 16.87±5.89 days. The most common site for leakage was at the cardio-esophageal junction (91.3%) compared to the body of the stomach (8.7%). The maximum diameter of the collection intraabdominal ranged from 4-12 cm with a mean of 7.43± 1.86 cm. Patients suffered from fever (95.7%), pain (69.6%) and tachycardia (69.6%). The leucocytic count ranged from 9.5-17.5 x 103 . The mean time for endoscopy was 2.96±0.77 days. Closure was achieved in 19 patients out of 23 patients (82.6%) as evidenced by gastrograffin meal while 4 patients (17.4%) suffered from persistent fistulae. Time taken for closure was 60.95±14.28 days. Four patients had persistent fistulae. Two other patients had stenosis at the midbody after closure of the fistula due to excessive fibrosis.

Conclusion: The endoscopic internal drainage using double pig tail is a feasible method for the management of stable post sleeve gastrectomy leakage with localized collection. It yields satisfactory results especially if early intervention is initiated before a chronic fistula is developed. This is coupled by enteral feeding either by Ryle or feeding jejunostomy to ensure good nutritional status.