A novel, two-staged approach for the management of refractory complex leaks in fistulas post-laparoscopic sleeve gastrectomy. We have no disclosures. Therapeutic approaches such as endoscopic closure, diversion, and drainage for managing post-operative gastric leaks are done sequentially or in a combined manner. When these techniques fail, the patient is subjected to high-risk surgery in hostile anatomic environments. We describe a case of refractory gastric leak in fistula formation status post sleeve gastrectomy managed with a novel, two-staged approach, including an obtruded peg bumper and a self-expanding vascular plug. Our patient is a 61-year-old female who presented with a subdiapragmatic sleeve leak in fistula status post-laparoscopic sleeve gastrectomy. Previous endoscopies had identified a proximal sleeve leak with a disrupted staple line and fistulas communication into the subdiaphragmatic cavity. Her symptoms were unresponsive to watchful waiting, stenting with metal stent, septotomy, multiple attempts at endoscopic drainage, or occlusion with an 8-millimeter septal occluding device in the sinus tract. One month after the insertion of the septal occluding device, the patient was admitted due to shock and perisplenic collections on imaging. Perisplenic and abdominal percutaneous drains were placed. Endoscopy identified two fistulas tracts, which were interrogated, dilated to 4 millimeters, and stented with a soft 10 French by 22 centimeter stent extending from the gastric side of the fistula to the subdiaphragmatic tract near the percutaneous perisplenic drain and a double pigtail 10 French by 5 centimeter soft stent across the gastrogastric fistula tract as seen in the image on the bottom of the screen. Unfortunately, despite prior intervention, the patient was readmitted five months later due to intra-abdominal sepsis. A CT scan revealed an increase in the size of the subdiaphragmatic abscess in the setting of internal drainage. A CT scan revealed an abscess with disrupted staple line along with frank pus at the site. The fistula tract was dilated with a 10 millimeter balloon under fluoroscopic guidance and two double pigtail 7 French by 20 centimeter stents were placed in a transgastric configuration to drain the abscess to the stomach. At this point, it was postulated that the increased gastric sleeve pressure compared to the subdiaphragmatic pressure led to inadequate drainage to the stomach and recurrent abscesses. A two-step approach was devised based on the driving pathophysiology. Step 1. The leak was blocked with a modified obtruded peg bumper to isolate the abscess cavity from the sleeve leak and to create adequate negative pressure within the abscess cavity. This is seen more detailed in the image on the top right, which demonstrates the transcutaneous placement of the obtruded peg tube with a retrograde drain in the shaft of the peg tube into the abscess cavity in order to create negative pressure. Furthermore, no contrast leak is demonstrated and this is owed to the obtruded peg bumper that was placed to prevent any leak. Next, after elimination of the abscess cavity, the modified peg tube was removed and replaced with an 8 French double pigtail catheter to reduce the size of the peg tract. Secondly, after reducing the size of the linearized tract, under fluoroscopic guidance, a self-expanding vascular plug, which was made water-resistant by combining cyanoacrylate and a silicone one-way valve, was placed. This plug was sutured to a truncated ureteral stent to drain any serous fluid produced in the tract due to a foreign body. Endoscopy revealed a fistula with a ureteral stent in place which was removed and not shown in the video. A self-expanding vascular plug made water-resistant by cyanoacrylate and a silicone one-way valve was placed under fluoroscopic guidance through the fistula tract. Here we see the silicone valve along with the plug. This plug was sutured to a truncated ureteral stent and placed under fluoroscopic guidance. Appropriate placement was confirmed following no observation of contrast leak on fluoroscopy. Repeat CT scan showed no residual fluid or gas collection. At 7-week follow-up, the patient endorsed improvement in symptoms and resumed her diet. Planned surgery was canceled with plans to remove the 7 French stent in 5 weeks. Innovative solutions are required for patients with refractory post-surgical leaks. In patients with recurrent abscesses and management unresponsive to traditional drainage, septotomy, and stenting, it is crucial to consider underlying pathophysiology such as inadequate negative pressure. By combining an obtruded peg bumper and downsizing the fistula tract to eventually sealing it with a water-resistant plug, we successfully treated a case of refractory post-operative gastric sleeve leak and fistula. Leaks and fistulas following sleeve gastrectomy are rare complications that require a multi-modality approach for management. We successfully managed a refractory leak with a novel two-staged approach using an obtruded peg bumper with negative intracavitary pressure to resolve the abscess cavity followed by a modified vascular plug to stop the leak.

refractory gastric leak

fistula formation

laparoscopic sleeve gastrectomy

abscesses and sepsis

two-staged approach