Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality. OBJECTIVES: To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG. SETTING: University hospital, Israel. METHODS: Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m2) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage. RESULTS: There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46). CONCLUSIONS: Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.

Transanal Endoscopic Microsurgery Implementation in Ultra-Low Anterior Resection.

BACKGROUND: Distal rectal cancer resection is an ongoing challenge for the colorectal surgeon. In recent years new technical approaches, especially with implementation of transanal platforms were developed to help in the visualization and resection of these tumors. Nevertheless, the use of these platforms is demanding with significant complications during the onset phase. METHODS: Patients with very low rectal cancer were operated on in a single tertiary center with a combined abdominal and transanal endoscopic microsurgery (TEM) approach. Demographic, pathological, and surgical data were collected retrospectively with an emphasis on distal margin involvement. RESULTS: Nineteen patients were operated on during the study period. All patients had negative distal resection margins with a low complication rate. The distant metastasis and local recurrence rates were low with a mean follow-up of 2 years. CONCLUSIONS: TEM provides an appealing and viable option for the resection of low rectal cancer in a combined transabdominal and transanal approach in patients with a good response after neoadjuvant treatment. This is one of the available platforms a colorectal surgeon might benefit from having in his armamentarium. It has a very low complication rate with maintenance of oncological principles, enabling a clear visualization of the distal rectum, and thus ensures free distal resection margins.