Successful Closure of Multiple Post-bariatric Surgery Fistulas Using Modified Internal and External Endoscopic Vacuum Therapy: A Case Report

Leaks and fistulas following bariatric surgery are serious complications associated with sepsis, malnutrition, and high morbidity. Endoscopic vacuum therapy (EVT) has emerged as an effective minimally invasive alternative for the management of transmural defects of the upper gastrointestinal tract. Recently, low-cost modifications using conventional hospital supplies have been developed to expand their applicability in resource-limited settings. We present the case of a 46-year-old female patient with a history of multiple bariatric surgeries: sleeve gastrectomy (2017), Roux-en-Y gastric bypass (2019), and revisional surgery in 2024 for candy cane syndrome. In the immediate postoperative period, she developed necrotizing acute pancreatitis and septic shock secondary to gastric pouch leakage, requiring multiple laparotomies. She evolved with three fistulous tracts: one gastrocutaneous and two enterocutaneous, confirmed by gastrointestinal transit, contrast-enhanced tomography, and upper gastrointestinal endoscopy. Endoscopic management was performed using modified internal and external EVT constructed with a nasogastric tube, gauze, and antimicrobial dressing. Initially, an external system was placed under a hydrophilic guide through the fistulous tract. Subsequently, after overcoming jejunal stenosis with an ultrathin endoscope, an internal modified system was placed. Both systems were connected to continuous suction at 125 mmHg. After 29 days of treatment, clinical, endoscopic, and radiologic closure of the fistulous tracts was achieved. The patient showed favorable evolution, recovery of oral tolerance, and was discharged in good general condition. In conclusion, modified EVT, both internal and external, represents an effective and reproducible alternative for managing complex post-bariatric surgery fistulas. Its adaptation using low-cost hospital supplies may expand access to this technique in resource-limited healthcare systems, offering favorable outcomes in high-complexity scenarios.