Abstract
Background
Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance as the preferred option for treating obesity. Risks of leak and subsequent fistula after sleeve gastrectomy still present significant concerns in clinical practice. This current series presents unusual fistulas post-LSG and their surgical management.
Methods
The series presents chronic leaks that have progressed into fistulas. Three patients with fistulas are presented: gastrocolic, gastropleural, and gastrosplenic. Surgical intervention was warranted in all cases with en-bloc resection of the fistula with subtotal gastrectomy and Roux-en-Y esophagojejunostomy reconstruction. A subtotal colectomy with ileo-descending colon anastomosis was additionally necessary in the gastrocolic patient.
Results
The patients with the gastropleural and gastrosplenic fistulas were discharged home on postoperative Day 6 and Day 7, respectively. The patient with the gastrocolic fistula had an extended postoperative hospital course and was discharged home on postoperative Day 35. All cases were negative for staple line leaks. To date, the fistulas healed with no recurrence.
Conclusions
En-bloc resection of the fistula with proximal gastrectomy and Roux-en-Y esophagojejunostomy (PGRYEJ) is a surgical option to treat chronic staple line leakage when non-operative therapy is rendered ineffective. Adequate preoperative planning with optimization of nutritional status and control of local and systemic sepsis is paramount for ultimate success. A symptomatic leak requires immediate operation regardless of the time interval between the primary sleeve operation and appearance of the leak.
Similar content being viewed by others
References
Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2008;4(1):33–8.
Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–20. discussion 420–2.
Csendes A, Braghetto I, Leon P, et al. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg. 2010;14(9):1343–8.
Perez M, Brunaud L, Kedaifa S, et al. Does anatomy explain the origin of a leak after sleeve gastrectomy? Obes Surg. 2014;24(10):1717–23.
Márquez MF, Ayza MF, Lozano RB, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20(9):1306–11.
Fernandez AZ, DeMaria EJ, Tichansky DS, et al. Experience with over 3000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc. 2004;18(2):193–7.
Deitel M, Crosby RD, Gagner M. The first international consensus summit for sleeve gastrectomy (SG), New York City, October 25–27, 2007. Obes Surg. 2008;18(5):487–96.
Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2011;8(1):8–19.
Morales MP, Miedema BW, Scott JS, et al. Management of postsurgical leaks in the bariatric patient. Gastrointest Endosc Clin N Am. 2011;21(2):295–304.
Burgos AM, Braghetto I, Csendes A, et al. Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg. 2009;19(12):1672–7.
Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204(1):47–55.
Carucci LR, Turner MA, Conklin RC, et al. Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of postoperative extraluminal leaks with upper gastrointestinal series. Radiology. 2006;238(1):119–27.
Doraiswamy A, Rasmussen JJ, Pierce J, et al. The utility of routine postoperative upper GI series following laparoscopic gastric bypass. Surg Endosc. 2007;21(12):2159–62.
Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;21(10):1520–9.
Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26(6):1509–15.
Oshiro T, Kasama K, Umezawa A, et al. Successful management of refractory staple line leakage at the esophagogastric junction after a sleeve gastrectomy using the HANAROSTENT. Obes Surg. 2010;20(4):530–4.
Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis. Gastrointest Endosc. 2012;75(2):287–93.
Madan AK, Lanier B, Tichansky DS. Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass. Am Surg. 2006;72(7):586–90.
Dapri G, Cadière GB, Himpens J. Laparoscopic conversion of adjustable gastric banding and vertical banded gastroplasty to duodenal switch. Surg Obes Relat Dis. 2009;5(6):678–83.
Thodiyil PA, Yenumula P, Rogula T, et al. Selective nonoperative management of leaks after gastric bypass: lessons learned from 2675 consecutive patients. Ann Surg. 2008;248(5):782–92.
Thompson 3rd CE, Ahmad H, Lo Menzo E, et al. Outcomes of laparoscopic proximal gastrectomy with esophagojejunal reconstruction for chronic staple line disruption after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2014;10(3):455–9.
Iannelli A, Tavana R, Martini F, et al. Laparoscopic Roux limb placement over a fistula defect without mucosa-to-mucosa anastomosis: a modified technique for surgical management of chronic proximal fistulas after laparoscopic sleeve gastrectomy. Obes Surg. 2014;24(5):825–8.
Nedelcu AM, Skalli M, Deneve E, et al. Surgical management of chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis. 2013;9(6):879–84.
Serra C, Baltasar A, Pérez N, et al. Total gastrectomy for complications of the duodenal switch, with reversal. Obes Surg. 2006;16(8):1082–6.
Frikker MJ, Lucas RJ. Gastrocolic fistula caused by benign gastric ulcer in the patient who has not had prior operation. Case reports and review of the literature. Am Surg. 1986;52(8):446–51.
Perez-Tamayo A, Congreve DP, Bartolome JS, et al. Perforated benign gastrocolic fistula. Arch Surg. 1983;118(9):1105.
Karakousis CP, Greenberg PH. Gastrocolic fistula as a complication of benign gastric ulcer. Arch Surg. 1979;114(12):1426–8.
Schein M, Decker GAG. Colonic perforation—a complication of benign gastrocolic fistula. A case report. S Afr Med J. 1987;71(2):119.
Compliance with Ethics Guidelines
Conflict of Interest
The authors declare that they have no competing interests.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in the study. Regarding the informed consent being obtained from all individual participants for whom identifying information is included in this article, this does not apply.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Nguyen, D., Dip, F., Hendricks, L. et al. The Surgical Management of Complex Fistulas After Sleeve Gastrectomy. OBES SURG 26, 245–250 (2016). https://doi.org/10.1007/s11695-015-1788-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11695-015-1788-2