Septotomy and Balloon Dilation to Treat Chronic Leak After Sleeve Gastrectomy: Technical Principles

Abstract

Background

Chronic leaks after laparoscopic sleeve gastrectomy (LSG) are often difficult to treat by endoscopy metallic stent. Septotomy has been indicated as an effective procedure, but the technical aspects have not been detailed in previous publications (Campos JM, Siqueira LT, Ferraz AA, et al., J Am Coll Surg 204(4):711, 2007; Baretta G, Campos J, Correia S, et al., Surg Endosc 29(7):1714–20, 2015; Campos JM, Pereira EF, Evangelista LF, et al., Obes Surg 21(10):1520–9, 2011). We herein present a video (6 min) demonstrating the maneuver principles of this technique, showing it as a safe and feasible approach.

Methods

A 32-year-old male, with BMI 43.4 kg/m², underwent LSG. On the tenth POD, he presented with a leak and initially was managed with the following approach: laparoscopic exploration, drainage, endoclips, and 20-mm balloon dilation. However, the leak remained for a period of 6 months. On the endoscopy, a septum was identified between the leak site and gastric pouch, so it was decided to “reshape” this area by septotomy.

Septotomy procedure: Sequential incisions were performed using argon plasma coagulation (APC) with 2.5 flow and 50 W (WEM, SP, Brazil) over the septum in order to allow communication between the perigastric cavity (leak site) and the gastric lumen. The principles below must be followed:

• (1) Scope position: the endoscopist’s left hand holds the control body of the gastroscope while the right hand holds the insertion tube; the APC catheter has no need to be fixed. This avoids movements and unprogrammed maneuvers.

• (2) Before cutting, the septum is placed in the six o’clock position on the endoscopic view, by rotating the gastroscope.

• (3) The septum is sectioned until the bottom of the perigastric cavity (leak site).

• (4) That section is made towards the staple line.

• (5) Just after the septotomy, a Savory-Gilliard guidewire (Cook Medical, Indiana, USA) through the scope must be inserted until the duodenum, followed by 30-mm balloon (Rigiflex®, Boston Scientific, MA, USA) insertion. The balloon catheter must be firmly held during gradual inflation (maximum 10 psi) to avoid slippage and laceration. This allows increasing the gastric lumen.

• (6) Septotomy by electrocautery with a needle knife (Boston Scientific, MA, USA) can be made when an intensive fibrotic septum is present; bleeding is rare in this case.

In this case, the endoclip previously used was removed from the septum with forceps to avoid heat transmission. Small staples visualized in the fistula orifice were not completely removed due to technical difficulties and friable tissue.

Results

Two sessions were performed in 15 days, resulting in leak closure. The patient was submitted to radiological control 1 week after the second session, which revealed fistula healing, without gastric stenosis. The nasoduodenal feeding tube remained for 7 days, when the patient started oral diet. This patient was followed for 18 months without recurrence.

Conclusions

Septotomy and balloon dilation were initially performed on a difficult-to-treat chronic fistula after gastric bypass and named before as stricturotomy (Campos JM, Siqueira LT, Ferraz AA, et al., J Am Coll Surg 204(4):711, 2007). This procedure allows internal drainage of the fistula and deviates oral intake to the pouch. In addition, achalasia balloon dilation treats strictures and axis deviation of the gastric chamber, promoting reduction of the intragastric pressure. Septotomy and balloon dilation are technically feasible and might be useful in selected cases for closure of chronic leaks after LSG.