Fistula after Sleeve surgery – RARE – but to be detected very quickly to ensure healing.
Whatever the technique used, the quality of the surgeon or robot, the material used, a fistula can always occur in the postoperative course of Sleeve gastrectomy.
The section of the stomach to make this sleeve is always done by stapling the stomach with an automatic pincer introduced by laparoscopy. This automatic clamp (electric battery and single use) is introduced by one of the trocars and successively :
- pinches the stomach
- lays 6 rows of staples
- cuts the stomach between these rows of staples about 5 cm; 4 to 6 staple refills are used to cut the entire stomach.
At the end of the intervention, we obtain a sleeve closed laterally by 3 rows of staples. It is good practice to check the tightness of this suture by injecting a dye (methylene blue) into the mouth which swells the sleeve and checks for leaks.
RISK:
- The cicatrization of the stomach as in all tissues of the organism is a BIOLOGICAL phenomenon: the staples, the glue, the threads only keep in contact the tissues which can not heal in a few days except by the healing factors of blood supply.
- At the level of the upper part of this suture the sleeve poorly vascularizes since its whole left part has been devascularized by the section thus decreasing the contribution of these factors. The 2 sides of the sleeve do not heal and leave an opening (fistula) through which will flow the salivary gastric fluids which are extremely toxic. These liquids are poorly tolerated by the abdominal cavity resulting in abscess, then generalized peritonitis, very serious in the absence of suitable and rapid treatment.
- Other risk factors: BMI greater than 50, poorly monitored sleep apnea, diabetes and smoking.
SINCE PREVENTION IS IMPOSSIBLE : WHAT TO DO?
Diagnose as soon as possible the fistula which occurs in general towards the 4th day (extremes 2-20). The operated patient is immediately aware of the complication: abdominal pain, inability to eat, fever and chills, in short nothing to do with simple pain in the scars or a simple fatigue.
It is essential to contact your surgeon and be rehospitalized. A CT scan with ingestion of contrast medium is then performed by the mouth, which visualizes the fistula and possibly a beginning abscess. The fistula is usually small: a few millimeters. An intravenous antibiotic therapy is then quickly started and after a few days a specialized gastroenterologist will introduce through the mouth a small drain of a few centimeters in the fistulous path between the abscess and Sleeve. The abscess empties itself spontaneously into the digestive tract. Three weeks later, after a control CT scan, this small drain is removed by fibroscopy and everything goes back to normal without re-intervention.
There are less favorable cases in general due to delayed diagnosis of fistula. It is usually necessary to reoperate the patient by laparoscopy to evacuate the abscess. The hospitalization is long and the drainage more complicated, which may require other interventions, punctures …