1. Managing Chronic Fistulas after Bariatric Surgery Matthew Kroh,MD Assistant Professor of Surgery Cleveland Clinic Lerner College of Medicine Center for Surgical Innovation, Technology, and Education Bariatric & Metabolic Institute

2. Disclosures Research support from and/or consultant: –Covidien –Ethicon –Bard –Gore –Intuitive

3. Incidence Chronic fistulas increasingly common with increased bariatric procedures Unique to each operation Most common is gastro- gastric fistula Up to 50% in non-divided RYGB From 3-6% in divided

4. Extent of Problem Many patients asymptomatic Most common complaints: –Nausea, vomiting –Epigastric pain –Hematemesis Other: –Acute- sub-acute sepsis –Recurrent ulceration –Weight regain –Chronic or acute bleeding Approach needs to be tailored to presentation

5. Classification of Fistulas Chronicity –90 days to 12 months –Greater than 12 months Etiology –Acute complications with late manifestation Leak, sub-clinical Technical –Chronic process Marginal ulceration- Smoking, NSAID’s Foreign body Carcinoma

6. Initial Operations Resulting in Fistulas Roux en-Y gastric bypass –G-J –Remnant or pouch staple line –Foreign body in banded bypass procedures Sleeve gastrectomy –E-G junction –Incisura obstruction Vertical banded gastroplasty –Pouch to stomach via undivided staple line –Eroded band

7. Types of Fistulas Gastro-gastric –Pouch to remnant most common- RYGB –Pouch to native stomach- VBG, non-divided RYGB Gastro- and Entero-cutaneous –Any procedure Gastro-pleural and Gastro-mediastinal –Any procedure, seem to be more common after sleeve gastrectomy

8. Principles of Therapy Define anatomy –Initial operation and current fistula involvement Control sepsis Improve nutrition and provide enteral access Drain and Debride Reconstruct –Open –Laparoscpic –Endoscopic

9. Anatomic Considerations Operative notes Upper endoscopy Upper GI CT (maybe) Fistula tract injection (maybe)

10. Stage Repair Urgent/emergent intervention for sepsis or bleeding Wide drainage –Surgical, endoscopic, radiologic Debridement of non- viable tissue Enteral access –Naso-enteric or surgical Abscess s/p RYGB

11. Initial Therapy Often medical management –PPI and carafate typically 3-6 months Hyperacidity From G-G fistula Or parietal cell inclusion Local ischemia at staples

12. Therapeutic Intervention Timing from initial operation Nutritional optimization Role for endoscopy Diagnosis and therapy Dictated by: Size Chronicity Operative risk of individual patients

13. Gastro-gastric Fistula Define anatomy –Pouch to remnant most common- RYGB At anastomosis or pouch vertical staple line –Marginal ulcer or weight regain –Pouch to native stomach- VBG, non- divided RYGB Weight regain

14. Gastro-gastric Fistula UGI –More sensitive –Especially if small Endoscopy –Operative planning

15. Surgical Management Symptomatic gastro-gastric fistula after RYGB Up to 27% leaks manifest with fistula Typically requires anastomosis resection if immediately adjacent to G-J If at vertical staple line, remnant gastrectomy with fistula Carrodeguas, SOARD 2005

16. 1.1% of 1796 patients undergoing RYGB 22 of 32 patients required remnant gastrectomy Mean 9 months from first operation to gastrectomy 3 required G-J resection 2 open procedures Limited folow-up

18. Endoscopic Management Failed medical management Small fistula Sepsis absent Foreign body removed Multiple techniques Fibrin glue efficacy varies Described with vicryl plugs Papavramedis 2008 J Gastro Hep Truong 2004 Surg Endosc

19. Sleeve Gastrectomy Fistulas from chronic leaks May be gastro- cutaneous, pleural Difficult to manage May require total gastrectomy and Roux esophago- jejunostomy as definitive procedure

20. Sleeve Gastrectomy

22. Future Endoscopic Approaches US GI Cobra System TM Bard EndoCinch TM Use of specific brand identified instruments for reference only. No promotional bias is inferred.

23. Endoscopic Approaches Endoscopy offers: –Less invasive approach –Endoluminal approach circumvents operative field Newer tools are coming for both diagnostic and therapeutic intervention Still need to adhere to surgical principles –Tissue apposition –Foreign body removal –Durability?

24. Conclusions Complex Require algorithmic approach Often require staged, multi-disciplinary approach Tailor to: –Type of initial operation –Addressing current patient needs –Long-term goals