Endoscopic septotomy with argon plasma coagulation (ES-APC) for the management of refractory postbariatric surgery fistulas and leaks (with video): results from a tertiary referral center.

BACKGROUND

Refractory late and chronic leaks or fistulas after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) represent a major therapeutic challenge, particularly after failure of conventional endoscopic or combined approaches. Endoscopic septotomy with argon plasma coagulation (ES-APC) restores internal drainage by eliminating the septum separating the perigastric cavity or fistulous tract from the gastric lumen.

OBJECTIVES

This study evaluated the efficacy and safety of a standardized ES-APC technique.

SETTING

Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Paris, France.

METHODS

This retrospective analysis of prospectively collected data included consecutive adult patients with refractory late or chronic postbariatric leaks or fistulas treated with ES-APC between September 2019 and August 2025 at a tertiary referral center. ES-APC consisted of stepwise septal ablation using standardized APC settings to achieve wide cavity-lumen communication, followed by systematic placement of a through-the-scope metallic clip to promote ischemic completion and reduce bleeding or perforation risk. The primary outcomes were technical success (TS) and clinical success (CS); the secondary outcomes included recurrence, adverse events (AEs), and long-term durability.

RESULTS

Sixty-four patients were included (76.6% female; mean age 40.8 6 11.2 years), predominantly after SG (95.3%). At septotomy, 25% of defects were classified as late and 75% as chronic according to the Rosenthal classification. Patients had undergone a median of 4 prior treatments (interquartile range [IQR]: 3-5). A median of one ES-APC session (IQR: 1-2) was required, with a median procedural time of 15 minutes (IQR: 12-22). TS was achieved in all cases (100%). CS was obtained in 93.7% (60/64), with one recurrence (1.7%) successfully managed endoscopically. CS was significantly lower in patients with gastrocutaneous fistula (86.7% versus 100%, P = .04). No major endoscopy-related AEs were observed. Durable clinical resolution was confirmed after a median follow-up of 44 months.

CONCLUSIONS

ES-APC is a safe, standardized, and highly effective minimally invasive technique for refractory late and chronic postbariatric leaks and fistulas, offering durable healing while limiting the need for high-risk surgical revision.