Endoscopic Kehr’s T-Tube Placement to Treat Persistent Large Gastro-cutaneous Fistula After One Anastomosis Gastric Bypass: Video Demonstration

Background We aim to show the endoscopic placement of a T-tube to treat a persistent large gastro-cutaneous fistula after OAGB. Methods We present the case of a 46-year-old woman with BMI of 48 kg/m2, who underwent OAGB and was re-operated on the 2nd postoperative day (POD) for leakage. Washing and drainage of the abdominal cavity was performed, and no fistulous orifice was identified. An upper gastrointestinal (GI) endoscopy was performed at POD 20 for the persistence of leakage of 150 ml/day by the drain and a gastric fistulous orifice of 2 cm was detected. Results At POD 22, under general anesthesia, upper GI endoscopy was performed and a T-tube was placed in the fistulous orifice with a “rendez-vous” technique (as demonstrated in the Video), placing the T branch in the digestive lumen pressed against the wall and the long part of the T exiting at the cutaneous orifice. The T-tube was clamped after 3 days and the patient could be gradually re-fed. The patient was discharged 8 days after the procedure, with perfect clinical tolerance and no complications. The ablation of the tube one was performed on POD 84. No relapse occurred during a follow-up of 48 months. Conclusion Persistent large gastro-cutaneous fistulas with an orifice bigger than 1 cm in diameter are difficult to manage. The endoscopic placement of a T-tube seems a useful option, which may facilitate the healing of the fistula. Further studies are needed to better define the role of this procedure. Supplementary Information The online version contains supplementary material available at 10.1007/s11695-022-06285-5.


Introduction
Persistent large gastro-cutaneous fistulas after one anastomosis gastric bypass (OAGB) are difficult to treat. Endoscopic T-tube placement has been described with promising results [2]. In this article, we aim to show the endoscopic placement of a T-tube to treat a large gastric fistula after OAGB.

Materials and Methods
We present the case of a 46-year-old woman with a BMI of 48 kg/m 2 , who underwent OAGB and was re-operated on the 2nd postoperative day (POD) for severe sepsis. During the re-laparoscopy at POD 2, washing and drainage of the abdominal cavity was performed, and no fistulous orifice Key points • The treatment of persistent large gastro-cutaneous fistulas after OAGB is challenging.
• T-tube placement in the fistulous orifice by laparoscopy has been reported.
• T-tube placement in the fistulous orifice by endoscopy may be effective and advantageous. was identified. An upper gastrointestinal (GI) endoscopy was performed at POD 20 for the persistence of leakage of 150 ml/per day by the drain and a gastric fistulous orifice of 2 cm was detected. Reference endoscopic treatments were judged not useful in this case (Pigtail was not suitable because the orifice was too large, a stent because of OAGB). The placement of a T-tube by endoscopy was proposed. The placement of the T-tube by laparoscopy is part of the therapeutic arsenal in case of fistulas after OAGB [1]. We have extended its use to the endoscopic route to reduce the invasiveness of the procedure [2].

Results
The patient was supine under general anesthesia. An upper GI endoscopy was performed at POD 22, objectifying a wide gastric fistula orifice. The "rendez-vous" technique (demonstrated in the Video) for T-tube placement included: (1) placement of a Boston Scientific Jagwire® guide wire along the drain path from the stomach to the skin orifice via the fistula; (2)

Conclusion
Persistent large gastro-cutaneous fistulas with an orifice of more than 1 cm in diameter are difficult to manage. The endoscopic placement of a T-tube seems a useful option, which may facilitate the healing of the fistula. It is based on the intense inflammatory reaction around the latex T-tube. Further studies are needed to better define the role of this procedure.
Funding Open access funding provided by Università degli Studi di Roma La Sapienza within the CRUI-CARE Agreement.

Declarations
Ethics Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board of the hospital and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent to Participate
Written informed consent was obtained from all individual participants included in the study.

Conflict of Interest
The authors declare no competing interests.
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