Post written by Khanh Hoang Nicholas Le, MD, MS, from the University of California San Diego Medical Center, San Diego, California, USA.

This video describes a 48-year-old woman with history of a mini-gastric bypass converted to a Roux-en-Y gastric bypass who was found to have a gastric pouch staple-line (GPSL) leak, later complicated by a gastrogastric (GG) fistula and an enterocutaneous fistula.

With continued leak after single esophageal stent placement and subsequent stent-over-stent placement, endoscopic vacuum therapy (EVT) was pursued.

Although the GPSL leak shrunk significantly with EVT, it later formed a GG fistula, a contraindication to continued EVT. Given the high failure rate of the closure of enteral fistulas, the team decided to deploy a lumen-apposing metal stent into the GG fistula to allow it to mature and remain patent.

Months later, because of inflammation from prior interventions including esophageal stents, surgical drains, and a wound vacuum, the patient developed an enterocutaneous fistula 4 cm distal to the GG fistula. This was closed with a ventricular septal defect cardiac septal occluder.

On follow-up 15 months after initial EVT, the patient was doing well, tolerating a regular diet, and at her lowest body mass index (34) and weight (180 pounds), down from 58 and 307, respectively.

In other case reports, EVT has been described, but this case is notable in showing multiple potential adverse events and their management. This patient’s story serves as a perfect example of the importance of close follow-up and reassessment at every step.

Given EVT resulted in significant reduction in the size of the GPSL leak, a clinician could have pre-emptively considered EVT as effective in that sense. However, a crucial turning point was recognizing development of the GPSL into a GG fistula, a contraindication to continued EVT.

We describe our approach to EVT, demonstrating step-by-step set-up, the procedure itself, and potential adverse events. This complex case provides multiple decision points as examples to teach clinical decision-making in the setting of complex anatomy, including but not limited to the decisions to pursue EVT initially, to discontinue EVT given development of the GG fistula, and to keep the GG fistula patent instead of closing it.

These decisions in combination with repeated assessments of risk versus benefit were key to the successful management of this complicated case and will be essential to optimal care of similar patients.

A, The original 1.8-cm gastric pouch staple-line leak. The lumen on the right is the gastrojejunal anastomosis, and the lumen on the left is the anastomotic defect into the peritoneum with 2 blue surgical drains. B, First esophageal stent placement with an endoscopic clip for anchoring. C, Second esophageal stent placement overlapping the first esophageal stent. D, Over-the-scope clip used to anchor the stent-over-stent placement.

Read the full article online.

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