Endoscopic Septotomy for Post-Bariatric Surgery Pistula Primary Author Mateus Mugosian Co-Authors Mateus Funari, Epifanio Júnior, Rodrigo Rocha, Diogo de Moura, Thiago Sousa, Eduardo de Moura The authors have nothing to disclose. A 67-year-old female patient underwent a Rooks NY gastric bypass surgery 8 months ago. Her BMI before the surgery was 48 and her BMI after surgery was 25. However, she complicated with a gastrocutaneous fistula, which was treated without success with nasoenteric catheter. Eight months after surgery, the patient was referred for an endoscopic assessment. Here we can see the gastric pouch and the gastrointestinal anastomosis. By pulling up the scope, we can observe sutures in the greater curvature of the gastric pouch. We performed the removal of the suture with endoscopic seizures. After the removal of the suture, we can observe a perigastric cavity with a fistulose orifice at the bottom of it. Delimitating the cavity, we observe also a septum. With ergon-plasma coagulation, we treated the fistulose orifice to help closing it. A guide wire was placed in the fistulose tract and was externalized through the cutaneous orifice. A 7-framed double pigtail was inserted through the guide wire. As final aspect of the first procedure, we can observe the septum and a well-located 7-framed pigtail stent through the fistulose orifice. Continuing the case, a bariatric surgery complicated with a gastrocutaneous fistula. Eight months after the surgery, endoscopic treatment with suture removal, ergon-plasma coagulation and pigtail stent insertion. The gastroenteric leak through the cutaneous orifice was reduced, but was not solved. After three months of the endoscopic procedure, an endoscopic reassessment was performed. The pigtail stent was removed. After the removal of the pigtail stent, the fistulose orifice caliber was reduced, but not completely closed. The septum was probably perpetuating the fistula. We performed then a septotomy using a knife with isolated ceramic tip. The electro-surgical unity mold was endocut Q. A fully covered self-expandable metallic stent was deployed to assist the fistula closure. The stent's proximal end was fixed with endosuture to avoid migration. Continuing the case, bariatric surgery complicated with a gastrocutaneous fistula. Eight months after the surgery, endoscopic treatment with suture removal, ergon-plasma coagulation and pigtail stent was performed. Three months after the first endoscopic treatment, a septotomy and a fully covered self-expandable metallic stent placement was performed. After one month, the patient presented clinical closure of the cutaneous fistulose orifice with good soft dyent acceptance. In the endoscopic reassessments, we can observe that the fistulose orifice was completely closed. We can see the septum cutted in the middle of it, and we can see the cutaneous orifice also closed. We can observe that there is no more a perigastric cavity, which reduces the local pressure and contributes to the fistula closure. Conclusion. Endoscopic septotomy reduces the intracavity pressure and assists fistula closure. Therefore, it is a safe and effective alternative to treat a post-bariatric gastrocutaneous fistula.

gastrocutaneous fistula

Rooks NY gastric bypass surgery

endoscopic assessment

ergon-plasma coagulation

self-expandable metallic stent