José Humberto Giordano-Nappi

Endoscopic treatment of Roux-en-Y gastric bypass-related gastrocutaneous fistulas using a novel biomaterial

BackgroundRoux-en-Y gastric bypass (RYGB) is amongst the commonest surgical intervention for weight loss in obese patients. Gastrocutaneous fistula, which usually occurs along the vertical staple line of the pouch, is amongst its most alarming complications. Medical management comprised of wound drainage, nutritional support, acid suppression, and antibiotics may be ineffective in as many as a third of patients with this complication. We present outcomes after endoscopic application of SurgiSIS®, which is a novel biomaterial for the treatment of this complication.DesignA case series of 25 patients.MethodsTwenty-five patients who had failed conservative medical management of gastrocutaneous fistula after RYGB underwent endoscopic application of SurgiSIS®—an acellular fibrogenic matrix biomaterial to help fistula healing.Main outcome measuresFistula closure as assessed by upper gastrointestinal imaging and endoscopic examination.Results In patients who had failed medical management lasting 4–25 (median, 7) weeks, closure of the fistulous tract was successful after one application in six patients (30%), two applications in 11 patients (55%), and three applications in three patients (15%). There were no procedure-related complications.ConclusionsEndoscopic application of SurgiSIS®—an acellular fibrogenic matrix—is safe and effective for the treatment of gastrocutaneous fistula after RYGB.

Transgastric access By balloon overtube for intraperitoneal surgery

The final frontier in endoscopy is the peritoneal cavity which was recently reached through natural orifice transluminal endoscopic surgery (NOTES). Endoscopic perforation caused by NOTES has been the major challenge for this procedure because of the risk of peritonitis and consequent complications. We describe in a dog model the use of an overtube system, one of them with a balloon, to access the peritoneal cavity by NOTES. It permits direct access to the peritoneal cavity from the mouth and also allows the performance of a controlled perforation and provides conditions for a safe closure of the gastric wall.

Experiência inicial no tratamento endoscópico de fístulas gastrocutâneas pós-gastroplastia vertical redutora através da aplicação de matriz acelular fibrogênica

BACKGROUND: Roux-en-Y gastric bypass is one of the most commonly performed bariatric surgeries in Brazil. Gastric leaks are relatively uncommon and potentially dangerous complications. The initial management of gastric leaks consists in adequate drainage, nutritional support, antibiotics and acid suppression. In almost 30% of the cases the fistula will become chronic. AIM: A novel peroral endoscopic treatment of gastric leaks in Roux-en-Y gastric bypassed patients is presented. METHODS: An acellular biomaterial was endocopically placed in the fistulous orifice in order to promote healing and avoid surgery in 25 patients. The time between fistula diagnosis and endoscopic treatment varied from 4 to 25 weeks (median: 7 weeks). RESULTS: Endoscopic treatment was successful in 20 (80%) patients. Fistula closure was obtained after one, two and three sessions in 6 (30%), 11 (55%) and 3 (15%) patients, respectively. No procedure related complications were observed. CONCLUSION: Endoscopic repair of gastric leak after Roux-en-Y gastric bypass by using an acellular biomaterial is safe and effective. However two or three endoscopic sessions are usually needed.

A new large-caliber trocar for percutaneous endoscopic gastrostomy by the introducer technique in head and neck cancer patients.

BACKGROUND AND STUDY AIMS In many patients, percutaneous endoscopic gastrostomy (PEG) can be limited by digestive tract stenosis. PEG placement using an introducer is the safest alternative for this group of patients, but the available devices are difficult to implement and require smaller-caliber tubes. The aim of this study was to evaluate the modification of an introducer technique device for PEG placement with regard to the following: procedure feasibility, possibility of using a 20-Fr balloon gastrostomy tube, tube-related function and problems, complications, procedure safety, and mortality. PATIENTS AND METHODS Between March 2007 and February 2008, 30 consecutive patients with head and neck malignancies underwent introducer PEG placement with the modified device and gastropexy. Each patient was evaluated for 60 days after the procedure for the success of the procedure, infection, pain, complications, mortality, and problems with the procedure. RESULTS The procedure was successful in all cases with no perioperative complications. No signs of stomal infection were observed using the combined infection score. The majority of patients experienced mild-to-moderate pain both in the immediate postoperative period and at 72 hours. One major early complication (3.3%) and two minor complications (6.7%) were observed. No procedure-related deaths occurred during the first 60 days after the procedure. CONCLUSION The device modification for PEG using the introducer technique is feasible, safe, and efficient in outpatients with obstructive head and neck cancer. In this series, it allowed the use of a larger-caliber tube with low complication rates and no procedure-related mortality.