Dados do Trabalho

Título

OTSC (Padlock Clip) as an endoscopic rescue method for a severe post-bariatric complication

Apresentação do Caso

A 28-year-old man, submitted to a Roux-en-Y gastric bypass reconstruction, evolved with abdominal sepsis and diagnosis of 900 ml of subdiaphragmatic collection, in the first postoperative week. Percutaneous drainage of pus was carried out without any better responses, culminating in a severe septic shock, intubation, tracheostomy, parenteral diet and the administration of large spectrum antibiotics over a long period of time. On the 30th postoperative day, the patient was submitted to an endoscopic evaluation showing dehiscence of the vertical stapling line of the gastric pouch, formation of a perigastric complex cavity and a gastrogastric fistula, confirmed by CT scan. The placement of a fully-covered SEMS with Shim's anti migration technique system was done, remaining in place for 6 weeks. The patient evolved with good clinical improvement, starting an enteral diet for 15 days and, later, an oral diet, being decannulated from his tracheo, receiving hospital discharge 30 days after the prosthesis placement. Endoscopic and tomographic revision 6 weeks after the beginning of the endoscopic treatment showed a complete resolution of the perigastric cavity, despite a persisting gastrogastric fistula confirmed by tomography and contrast extravasation during endoscopy. Thermal ablation of the gastro-gastric fistula in the correspondent pouch area was then performed, followed by the successful application of a Padlock clip in the fistulous ostium. 2 months after the beginning of the endoscopic treatment, the patient returned for an out-patient evaluation with no complaints, having lost 36 kg, showing a control CT scan with no fistulas or collections signs, an intact gastric pouch, without axis deviation and a suitable gastrojejunal anastomosis size.

Discussão

Endoscopic techniques became the first-line therapy in bariatric surgery-related complications due to it being a less invasive procedure, allowing earlier enteral feeding, shorter hospital stay rates and lower costs. SEMS, TTSC and OTSC, tissue sealants, suturing systems and internal drainage techniques can be carried out and combined, remaining the best option.

Comentários finais

We demonstrated a successful combined endoscopic treatment, using SEMS and Padlocks (OTSC), in order to reverse a case of leak and dehiscence of the gastric pouch after a RYGB surgery. However, more prospective and randomized studies are needed to provide significant comparisons with the techniques used and to establish the clinical safety of this technique.

Palavras-Chave

Bariatric surgery; Endoscopy; Fistula; Gastric by-pass; ; Leak; SEMS.