Identification and Treatment of Fistulas and Chronic Cavities

Acute gastrointestinal leak following bariatric surgery is a severe complication, associated with a significant morbidity and mortality. While many centers are increasingly experienced in managing these acute leaks, when these techniques fail, fistulous connections form between the gastrointestinal tract and numerous other organs and structures. Moreover, the presence of foreign bodies, such as reinforcing silicone rings, and marginal ulceration can result in fistulous connections months or years after bariatric surgery. Endoscopic evaluation is critical in delineation of the anatomy and fistula. Management of these fistulae can be complex and involve multiple modes of therapy, repeat interventions, and a multidisciplinary team of providers. Fortunately endoscopic therapy is possible in many cases. When effectively utilized, endoscopy may avoid major operations and its attendant morbidity and mortality, or serve as a temporizing measure, allowing resolution of sepsis and augmentation of nutritional status prior to definitive operative intervention. Successful endoscopic management is based on both familiarity and facility with a spectrum of endoscopic techniques and technologies, including effective use of enteral stents, thermal technology, and various clips, glues or sealants, staplers, and suturing devices, among others. This chapter will review endoscopic techniques for various types of fistulae reported after bariatric operations.