An Uncommon Adverse Event of Endoscopic Vacuum Therapy and Pigtail Stent Placement for the Treatment of Bariatric Surgery Leak

ABSTRACT

Sleeve gastrectomy–transit bipartition is an effective metabolic surgery for obesity, offering significant weight loss and comorbidity resolution. Although generally safe, complications such as fistula, bleeding, or abscess may occur. Fistula remains a major challenge, often requiring endoscopic management. Endoscopic internal drainage using double-pigtail plastic stents has emerged as a minimally invasive and effective option, although stent-related adverse events, including migration or intestinal perforation, can occur. Colonic perforation from plastic stents is extremely rare, with only 59 cases reported. This case describes a late colonic perforation successfully managed endoscopically using a metallic clip, avoiding surgical intervention and achieving complete recovery.

INTRODUCTION

Sleeve gastrectomy–transit bipartition has emerged as an effective alternative for obesity treatment. Despite its overall safety, the adverse event rate, although low (<5%), may include fistula, bleeding, infection, abscess formation, and respiratory or urinary sepsis.¹ Among these, fistula remains one of the most challenging adverse events, often requiring multimodal therapeutic strategies.^1,2

More recently, endoscopic internal drainage achieved through the placement of double-pigtail plastic stents across the fistulous tract has been established as a safe and effective alternative, particularly in early fistulas, allowing resolution of the condition while avoiding morbid reoperations.² Although considered of low risk, this technique is not free of adverse events, which include stent migration and, more rarely, intestinal perforation.^3,4

The literature reports on 59 cases of colonic perforation associated with plastic stent.^5,6 As expected, the optimal management of this uncommon adverse event remains controversial. Reported therapeutic strategies include surgery alone, combined surgical and endoscopic approaches, simple endoscopic stent removal without additional intervention, or, in selected cases, defect closure with metallic clips.

The purpose of this case report was to illustrate an unusual adverse event related to long indwelling time of a plastic stent used to treat a postoperative fistula, and how its endoscopic management with a dedicated metallic clip may represent an effective alternative to surgery.

CASE REPORT

A 60-year-old male patient with morbid obesity (maximum weight 163 kg, body mass index 45 kg/m²) and history of type 2 diabetes, hypertension, and dyslipidemia underwent laparoscopic bariatric bipartition in December 2023. Four days later, he developed abdominal pain and fever. Computed tomography (CT) demonstrated dehiscence at the angle of His with oral contrast extravasation, pneumoperitoneum, and a perisplenic collection. Initial management included laparoscopic cavity drainage, followed by percutaneous drainage with a pigtail catheter (Figure 1).

Figure 1.

Computed tomography–guided percutaneous drainage of a perisplenic collection (at the arrowhead).

Given persistence of the collection, serial endoscopic interventions were undertaken. The first esophagogastroduodenoscopy revealed a 9-mm dehiscence at the angle of His (Figure 2), preventing scope passage, and a modified endoscopic vacuum system (nasogastric tube 18 Fr wrapped with gauze and Ioban) was placed with its distal segment positioned intracavitary and intraluminal. Between December 2023 and January 2024, multiple sessions of endoscopic vacuum therapy (EVT) were performed, each time placing or exchanging the system under endoscopic and radiologic guidance. EVT systems were exchanged regularly, with concomitant placement of a nasoenteric tube for enteral feeding. These procedures progressively reduced cavity size and controlled sepsis (Figure 3). Antibiotic coverage was administered throughout this period to manage ongoing contamination and sepsis.

Figure 2.

Endoscopic view of the angle of His, approximately 43 cm from the upper dental arch, showing a residual gastric fundus with a dehiscence of about 9 mm in diameter, preventing scope passage.

Figure 3.

(A) Endoscopic view during the second procedure, showing the fistulous orifice at the angle of His before vacuum placement. (B) Third session of endoscopic vacuum therapy with intracavitary positioning of the modified vacuum system.

Despite serial EVT exchanges, follow-up CT demonstrated a persistent perisplenic collection and a percutaneous drain was left in place. Because of ongoing contamination and incomplete resolution, during the endoscopic procedure on January 16, 2024, a double-pigtail stent was inserted with its distal end in the perisplenic cavity (Figure 4), in combination with EVT and a nasoenteric feeding tube.

Figure 4.

(A) Endoscopic view showing placement of a double-pigtail stent with its distal end positioned into the perisplenic cavity through the dehiscence at the angle of His. (B) Fluoroscopic image confirming intracavitary positioning of the pigtail drain.

The patient was discharged asymptomatic until January 2025, when he reported intermittent hematochezia without abdominal pain. A combined esophagogastroduodenoscopy and colonoscopy were performed, revealing transgastric migration of the pigtail drain with erosion into the transverse colon, supporting the symptoms aforementioned and establishing a gastrocolic fistula (Figure 5). Contrast-enhanced CT confirmed a perigastric collection with the 1 extremity of the pigtail stent inside the collection (Figure 5). Endoscopy demonstrated erosion of the stent through the gastric wall into the transverse colon (Figure 5).

Figure 5.

(A, B) Contrast-enhanced computed tomography scans (axial and coronal views) demonstrating the transgastric pigtail stent in place in close relation to the transverse colon (at the arrowhead). (C) Endoscopic views showing erosion of the pigtail stent through the gastric wall into the transverse colon (gastric view) (D), consistent with the formation of a gastrocolic fistula (colonic view).

The migrated pigtail stent was removed endoscopically. The gastric orifice at the angle of His was left under surveillance without clip placement because adequate drainage orifice was indispensable to facilitate secondary intention healing of the fistulous tract, whereas the colonic orifice in the transverse colon was closed with an over-the-scope-clip (OTSC). Fluoroscopic images documented the deployment and final position of the clip within the colon, with the last image confirming correct placement (Figure 6).

Figure 6.

Fluoroscopic sequence during endoscopic closure of the gastrocolic fistula. (A) The endoscope is positioned superiorly, with the colon visualized inferiorly; a through-the-scope (TTS) clip is positioned at the tip of the colonoscope and directed toward the colonic orifice. (B) Deployment phase of the clip over the fistulous tract. TTS clip ate the arrowhead. (C) Final image demonstrating the clip correctly positioned in the transverse colon at the fistula site (highlighted with a circle), after removal of the migrated pigtail stent through the gastric orifice.

Follow-up imaging in February 2025 confirmed absence of collections or contrast leak. Endoscopy showed complete closure of the fistulous tract with healthy mucosal healing, with the colonic clip remaining well positioned. The patient resumed oral intake without abdominal symptoms. At his most recent evaluation in December 2025, he weighed 93.9 kg (body mass index 25.7 kg/m²), remained asymptomatic, with normal labs. To sum up, a timeline clarifies the case:

Date/period	Event summary	Key management action
Dec 2023	Bariatric surgery → dehiscence/leak	Percutaneous drainage initiated
Dec 2023–Jan 2024	Persistent collection/sepsis	Multiple sessions of endoscopic vacuum therapy
Jan 16, 2024	Incomplete resolution	Insertion of double-pigtail stent
Late Jan 2025	Complication: hematochezia	Diagnosis: stent migration causing gastrocolic fistula
Endoscopic repair	Fistula closure	Stent removal + colonic orifice closure with through-the-scope clip
Feb 2025	Short-term follow-up (13 mo)	Fistula closure confirmed; absence of leak/collection
Dec 2025	Final follow-up	Patient asymptomatic (BMI 25.7)

DISCUSSION

In this case, we reported a double-pigtail stent that, after successfully treating a gastric-cavity fistula due to a sleeve gastrectomy–transit bipartition, migrated to the transverse colon in less than 1 year. This migration resulted in erosion and lower gastrointestinal bleeding as well as formation of gastric-colon fistula. The use of an OTSC (StarClip—Microtech) proved to be a simple, safe, and effective option to close the internal orifice, thereby preventing further fistulization.

Sleeve gastrectomies are known for a 33 to 46.2% rate of postoperative fistulas, most commonly located at the Hill angle.^7–9 Although surgical intervention was historically the standard of care, endoscopic management has emerged as a less invasive and increasingly preferred alternative. Internal drainage using double-pigtail stents allows for outpatient treatment with favorable outcomes in many cases.^7,8,10–13

However, the optimal timing for stent removal remains controversial. According to previous reports, the new fistula due to the stent occurred within 2 months to 1 year in various thoraco-abdominal sites such as spleen, abdominal wall, kidney, gallbladder, and bronchus.¹¹ This is the first case report in literature of a migrated pigtail stent after treatment for a postbariatric fistula, which resulted in a gastrocolic fistula, successfully treated by its removal and OTSC closure.

This case underscores 2 critical learning points about the successful endoscopic management of a rare complication: The importance of individualized assessment of stent duration highlights the potential risks of prolonged indwelling time and the demonstration that endoscopic clip closure proved to be effective. We advocate increased awareness regarding the timing of stent removal to prevent delayed adverse events, such as migration and fistula formation, despite the overall efficacy of this treatment modality; The long-term 15-month follow-up confirmed complete healing and sustained clinical remission.

DISCLOSURES

Author contributions: All authors meet the ICMJE criteria for authorship. L. Bicudo de Oliveira contributed to the conception of the work, discussion, and manuscript organization and is the article guarantor. MP Funari contributed to the procedure technique and execution. YR Fernandes contributed to the description and documentation of the case. AO Ardengh provided technical assistance during the procedure. E. Ide contributed to the overall case management. I. Mendonça Proença contributed to the management of the colonic fistula case. T. Franzini contributed to the organization and application of the vacuum system. MB Boghosian contributed to the management of the vacuum-assisted case. F. Maluf-Filho provided supervision and performed the final critical revision of the manuscript. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

ABBREVIATIONS:

BMI

body mass index

CT

Computed tomography

Dec

December

EGD

Esophagogastroduodenoscopy

EVT

Endoscopic vacuum therapy

Feb

February

Jan

January

OTSC

Over-the-scope-clip

SG-TB

Sleeve gastrectomy-transit bipartition

TTS

Through-the-scope