Ruptured giant splenic artery aneurysm with an exceptional concurrent gastric and transverse colonic fistula: A rare case report.

INTRODUCTION: Splenic artery aneurysm (SAA) is a focal dilation of the splenic artery with varying etiologies including atherosclerosis, arteritis, or trauma. Giant SAAs with a diameter of 10 cm is rare and can lead to severe complications like rupture and fistulas. Therefore, an accurate and timely diagnosis and treatment are important. PATIENT CONCERNS: A 50-year-old male presented with acute epigastric pain and hemorrhagic shock. Considering his symptoms and examination, ultrasound, multi-slice computed tomography and digital subtraction angiography results, a ruptured giant splenic artery aneurysm complicated with an exceptional gastric and transverse colonic fistula was suspected. DIAGNOSIS: Ruptured giant splenic artery aneurysm. INTERVENTIONS: Left anterolateral thoracotomy to control the severe aortic bleeding just above the diaphragm, aneurysmectomy, splenectomy, and closing the gastric and transverse colon perforations. OUTCOMES: Multi-slice computed tomography demonstrated the presence of splenic artery aneurysm in the distal third measuring (10 × 12 cm) in diameter with a true lumen measuring (7 × 3.5 cm) and a large hematoma extending to the greater and lesser gastric curvature. Intraoperatively, a large pulsating mass was detected occupying the epigastrium and the left hypochondrium with severe adhesions with the stomach and transverse colon. CONCLUSION: Giant SAA with a diameter of 10 cm is rare and is associated with severe complications. Therefore, successful treatment of splenic artery aneurysms involves prompt diagnosis, immediate surgical intervention to control bleeding, and tailored approaches like thoracotomy to control the thoracic aorta for better hemodynamic stabilization, aiming to eliminate the aneurysm and reduce complications effectively.

Management of fistulas in the upper gastrointestinal tract.

Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.

Laparoscopic Management of Gastrocolic Fistula in a Patient with a History of an Unusual Loop Gastric Bypass-a Video Vignette.

Gastrocolic fistula (GCF) is defined as an abnormal pathological communication between the epithelialized mucosal layers of the stomach and colon. In rare cases, complications following gastric bypass surgery, such as leakage or complicated marginal ulcers, may contribute to the development of a GCF. The laparoscopic approach for managing GCF involves a one-stage procedure that includes resection of the fistula and reconstruction of the gastrointestinal tract.

Gastropericardial fistula: A successfully operated heart code.

Gastropericardial fistula is a rare, extremely serious and life-threatening condition. Its most common aetiology is secondary to iatrogenic injury following gastric surgery. Clinical manifestations may be non-specific with precordial pain, simulating an acute coronary syndrome, and may be accompanied by electrocardiogram abnormalities. Diagnosis is made by thoracoabdominal computed tomography (CT) with oral and intravenous contrast. Treatment is surgical and consists of repair of the anomalous communication. We present the case of an 81-year-old male patient with gastropericardial fistula who underwent surgery, with the aim of reviewing the diagnosis and the appropriate therapeutic strategy.

Gastrosplenic Fistula and/or Splenic Abscess: A Rare and Refractory Complication Following Sleeve Gastrectomy.

Splenic abscess is a rare complication often associated with sleeve gastrectomy (SG) due to factors including local infections, distant infections, tumors, ischemia, and trauma, which presents substantial challenges. We report four cases of gastrosplenic fistula and/or splenic abscess after SG. Patient data, including demographics, comorbidities, diagnostic procedures, treatments, and outcomes, were recorded. Surgical techniques for SG adhered to established protocols. Four patients had a male-to-female ratio of 2:2, with an average age of 39.8 years and an average preoperative BMI of 38.9 kg/m2. All patients were readmitted due to recurrent fever and chills caused by splenic abscesses detected on CT scans, with an average admission duration of 16.5 weeks. Treatments varied from fasting and antibiotics to percutaneous drainage and surgical interventions. The average treatment duration post-diagnosis of splenic abscess was 37.25 weeks. Managing gastrosplenic fistula and/or splenic abscess is complex, underscoring the significance of prompt diagnosis and proper treatment. This highlights the need for heightened awareness among healthcare professionals to promptly recognize and manage this rare complication after SG.

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis.

BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

[Gastrocolic fistula as infrequent cause of chronic diarrhea in a patient with percutaneous radiological gastrostomy]. / Fístula gastrocólica como causa infrecuente de diarrea persistente en un paciente portador de gastrostomía radiológica percutánea.

Introduction: Introduction: gastrocolic fistula is an infrequent but severe complication of percutaneous gastrostomy. Clinical suspicion in the presence of chronic diarrhea of unknown etiology manifesting after percutaneous radiological gastrostomy (PRG) tube replacement is key to early detection and treatment. Case report: we report the case of a patient with PRG that began with chronic diarrhea after tube replacement and developed severe malnutrition. Initial treatment was not effective, studies were extended with the finding of this complication in a CT image. The use of this tube was discontinued with resolution of diarrhea and a favorable nutritional outcome. Discussion: this case report shows the importance of considering gastrocolic fistula in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.

Introducción: Introducción: la fístula gastrocólica supone una complicación infrecuente pero potencialmente grave de las sondas de gastrostomía. La sospecha clínica ante una diarrea de origen incierto que comienza tras el recambio de la sonda es clave para la detección y el tratamiento precoces. Caso clínico: se presenta el caso de un paciente portador de gastrostomía radiológica percutánea (PRG) que comienza con diarrea persistente tras el primer recambio de la sonda y desnutrición grave secundaria. Tras el fracaso de las medidas terapéuticas iniciales se amplían los estudios, con hallazgo de esta complicación en la imagen de TC. Se suspende el uso de esta sonda con resolución de la diarrea y evolución nutricional favorable. Discusión: este caso pone de manifiesto la importancia de incluir la fístula gastrocólica en el diagnóstico diferencial de la diarrea persistente en un paciente portador de sonda de gastrostomía.

Use of high-frequency electrical stimulation in gastrocutaneous fistula closure: a case report.

BACKGROUND: Gastrocutaneous fistula is a rare complication following Roux-en-Y gastric bypass, a commonly performed bariatric surgery. While most ECFs respond to conservative management, some do not close despite adequate nutritional support, infection source control, and drainage management. As such, the chronicity of these difficult-to-treat wounds can be physically and economically costly to patients. CASE REPORT: A 53-year-old female with a history of Roux-en-Y gastric bypass developed a gastrocutaneous fistula secondary to a perforated gastrojejunal ulcer, requiring immediate surgical intervention. After being discharged from the hospital, 37 days of conservative management and NPWT did not reduce the size of the fistula tract. To help control the patient's chronic abdominal pain and increase the rate of wound healing, the patient underwent treatment with HFES (20 kHz) delivered using a handheld transcutaneous electrical nerve stimulator. This electrotherapy was found to reduce the majority of the patient's pain within the first treatment session. The patient's fistula also began to decrease in size within 1 week of initiating treatment. CONCLUSION: This case report details the successful closure of a gastrocutaneous fistula after administration of HFES 3 times a week over the course of 25 days. The mechanism of action of HFES and its role in the wound healing process are also discussed.

Abdominal abscess caused by Raoultella ornithinolytica secondary to postoperative gastric fistula: case report and review of literature.

BACKGROUND: In recent years, Raoultella ornithinolytica (R. ornithinolytica) have attracted clinical attention as a new type of pathogen. A wide range of infections with these germs is reported, and commonly found in urinary tract infections, respiratory infections, and bacteremia. CASE PRESENTATION: We report the case of an elderly woman with liver abscess, choledocholithiasis and cholangitis, who developed gastric fistula and abdominal abscess after underwent choledocholithotomy, and R. ornithinolytica were isolated from the abdominal drainage fluid. The patient was treated with meropenem and levofloxacin and had a good outcome. CONCLUSIONS: To the best of our knowledge, case of isolating R. ornithinolytica from a patient with non-viscerally abdominal abscess was extremely rare. We share a case of a woman with non-viscerally abdominal abscess secondary to postoperative gastric fistula, R. ornithinolytica was isolated from the patient's pus, and the pathogenic bacteria may originate from the gastrointestinal tract. Based on this case, We should be cautious that invasive treatment may greatly increase the probability of infection with this pathogenic bacterium.

Fixation of the proximal flange of a lumen-apposing metal stent using a through-the-scope endoscopic suturing system to prevent stent migration in single-session EUS-directed transgastric ERCP: a pilot study.

BACKGROUND AND AIMS: With the global obesity pandemic, clinical scenarios requiring urgent ERCP in patients with gastric bypass surgery are on the rise, and single-session EUS-directed transgastric ERCP (SS-EDGE) can effectively address these technical challenges. The aim of this study was to evaluate and describe the safe and effective use of a through-the-scope endoscopic suturing system for anchoring the lumen-apposing metal stents (LAMSs) during SS-EDGE. METHODS: Six patients with Roux-en-Y gastric bypass (RYGB) underwent SS-EDGE at our center. A through-the-scope endoscopic suturing system was used for anchoring the LAMSs during SS-EDGE. RESULTS: Clinical and technical success was achieved in all 6 patients without any adverse events related to the procedure. No stent migration, pneumoperitoneum, or GI perforation was noted. At the 4-week follow-up, no stent migration was noted, and the through-the-scope suturing system remained anchored. LAMSs along with tacks were removed, and gastric fistulae were successfully closed endoscopically in all patients to prevent weight gain. CONCLUSIONS: Use of through-the-scope endoscopic suturing can be a safe, reliable, and potentially cost-effective novel technique for LAMS fixation to successfully perform SS-EDGE in RYGB patients.

Operative Complications Following Gastrostomy Tube Placement After Cardiac Surgery During Infancy.

INTRODUCTION: Gastrostomy tube (GT) placement is common in infants following repair of congenital heart defects. We aimed to determine rate of operative complications and predictors of short-term GT use to counsel parents regarding the risks and benefits of GT placement. METHODS: We reviewed infants aged <1 y with congenital heart disease who underwent GT placement after cardiac surgery between 2018 and 2021. Demographics and clinical data were collected and analyzed. Comparisons were made between infants who required the GT for more than 1 y and those who required the GT for less than 1 y. RESULTS: One hundred thirty three infants were included; 35 (26%) suffered one or more complication including wound infection (4, 3%), granulation tissue (3, 2%), tube dislodgement (10), leakage from the tube (9), unplanned emergency department visit (15), and unplanned readmission (1). Thirty-four infants used the GT for feeds for 1 y or less (26%) including 17 (13%) who used it for 3 mo or less. Fifty-six infants had their GT removed during the study period (42%), 20 of whom required gastrocutaneous fistula closure (36%). Thirty-three infants had a GT placed on or before day of life 30, 17 (52%) used the GT for less than 1 y, and 10 (31%) used it for 3 mo or less. CONCLUSIONS: GT placement is associated with a relatively high complication and reoperation rate. GT placement in infants aged less than 30 d is associated with shorter duration of use. Risks, benefits, and alternatives such as nasogastric tube feeds should be discussed in the shared decision-making process for selected infants.

A noninvasive treatment for gastro-mediastinal or gastro-pleural fistula after esophagogastrectomy.

Our objective was to assess the safety and efficacy of 3 tubes with or without covered esophageal stent placement for the management of gastro-mediastinal or gastro-pleural fistula. We retrospectively assessed the clinical data of 31 consecutive patients with gastro-mediastinal or gastro-pleural fistula treated by using a noninvasive treatment from February 2013 to July 2022. Patients received 3 tubes (jejunal feeding tube, gastrointestinal drainage tube and abscess drainage tube) with or without esophageal-covered stent placement. All patients received continue abscess drainage and nutritional support after procedure. The tubes and/or esophageal-covered stents were removed after fistula healing. All patients received 3 tubes placement and 11 patients with luminal narrowing received esophageal covered stent placement. Technically success was found in all patients, with no procedure-related death, esophageal rupture or massive hemorrhage. Abscess cavity disappeared in 22 patients, with a clinical success rate of 71.0%. All patients received esophageal stent placement were cured and stents were removed, for a median duration of 1.6 months (interquartile ranges [IQR] 1.4, 3.7). Three patients showed clinical improved, with markedly decreased abscess cavity and markedly shrunk fistula. The median survival was 30.8 months. The 1-, 3-, 5-year survival rates were 71.1%, 46.1% and 39.5%, respectively. A noninvasive treatment of 3 tubes with or without covered esophageal stent placement is safe and effective for gastro-mediastinal or gastro-pleural fistula after esophagogastrectomy.

Persistent Ostomy Following Percutaneous Endoscopic Gastrostomy Removal: Treatment Strategies.

PURPOSE OF REVIEW: The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy. RECENT FINDINGS: The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.

Endoscopic stent placement for the management of gastro-pleural and gastro-cutaneous fistula post laparoscopic sleeve gastrectomy: a case report.

BACKGROUND: Gastro-pleural and gastro-cutaneous fistulae formation are rare yet life-threatening complications post-bariatric surgery. To our knowledge so far only limited cases of gastro-pleural and gastro-cutaneous fistulae post gastric sleeve surgery have been reported in the literature with their corresponding management. Therefore, we are reporting a case of placement of an endoscopic stent in the management of gastro-cutaneous fistula post laparoscopic sleeve gastrectomy. CASE PRESENTATION: A 42 years old Pakistani, female morbidly obese patient, underwent laparoscopic sleeve gastrectomy. Within a week after the procedure, the patient presented with dyspnea. Workup showed a gastric leak for which percutaneous drain placement was done. Later, gastro-pleural and gastro-cutaneous fistulae were formed for which endoscopic fistula closure was done using a metallic stent. CONCLUSION: Endoscopic stent placement is an emerging field and it is considered safe and effective for the management of complications related to bariatric surgery.