Surgical Management of a Chronic Sleeve Gastrocolic Fistula with Near Total Gastrectomy and Roux-en-Y Reconstruction

Abstract

Background

Management of the leak is determined by the duration of the leak from the initial surgery. Acute leaks occurring less than 72 hours after surgery are best managed with reoperation and primary repair. Intermediate leaks, greater than 72 hours but less than 12 weeks, can be managed with non-operative management in non-septic patients. When non-operative management fails beyond 12 weeks the leak is considered a chronic fistula which are best treated with definitive operative management. Sub-total gastrectomy with Roux-En-Y reconstruction with gastrojejunostomy, has been reported with resolution of the fistula in over 90% of cases.

Objectives

To demonstrate the operative management of chronic sleeve gastrectomy leaks.

Methods

A 37-year-old male with a history of a sleeve gastrectomy, developed a chronic fistula between the distal gastric staple line and the transverse colon. After non-operative management failed the patient was taken to the operating room for a diagnostic laparoscopy with plans to perform a revision. A fistula between the distal sleeve staple line and the transverse colon was identified. The gastroesophageal junction was dissected and inspected, there was no fistula at the angle of His. A near total gastrectomy was then performed leaving a small gastric pouch. The colonic side of the fistula was oversewn. Roux-En-Y reconstruction was then performed.

Results

No leak identified at four-month follow-up.

Conclusion

Leak after sleeve gastrectomy can be difficult to manage. Chronic leaks do not respond well to non-operative management. Partial gastrectomy with Roux-En-Y reconstruction is a technically challenging option with good results.