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Fistula Following Laparoscopic Sleeve Gastrectomy: a Proposed Classification and Algorithm for Optimal Management

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Abstract

Background

Laparoscopic sleeve gastrectomy (LSG) is an accepted restrictive procedure with a hormonal component. There is no definitive course of treatment for post-LSG fistula; it remains a feared complication. We aimed to classify post-LSG fistulas and propose an algorithm to optimize their treatment.

Methods

Following primary and revisional LSG in obese patients, a retrospective observational study of fistulas was undertaken. Radiological studies were performed to identify anatomically distinct types of fistulas. An algorithm was elaborated for the classification and evolving treatment of each type of fistula.

Results

Twenty post-LSG fistulas were studied (13 [2.5%] from our center, 7 referred) with a mean body mass index of 43.1 ± 10.2 kg/m2 (32.0–76.0) and mean age of 33.1 ± 11.4 years (20.0–56.0). In all cases, the clinically suspected diagnosis was radiologically confirmed by water-soluble upper gastrointestinal series and double-contrast abdomino-pelvic CT scan. Three anatomical fistula types were characterized: type I, a small leak with no collection; type II, a leak with associated intra-abdominal abscess; and type III, a leak with multiple internal or external abscesses, a complex fistula. In accord with our algorithm, patients without sepsis received conservative treatment initially; this was sufficient for type I leaks. Type II abscesses received internal or external percutaneous drainage, and in some cases, stenting or endoprosthesis. Surgery was reserved for failure of conservative options and type III fistula. In cases of sepsis, surgery was mandatory.

Conclusion

A radiologically defined, anatomically based classification system and treatment algorithm proved effective in clinical management of post-LSG fistula.

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Acknowledgements

We thank J. N. Buchwald, Chief Scientific Research Writer and Director, Division of Scientific Writing, Medwrite Medical Communications, WI, USA, for substantive manuscript revision.

Funding Information

The authors appreciatively acknowledge financial support for development of the manuscript (not the performance of the study) by Baxter International, Westlake Village, CA, USA.

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Authors and Affiliations

  1. Middle East Institute of Health (MEIH), Bsalim, Lebanon

    G. Al Hajj & R. Chemaly

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  1. G. Al Hajj
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  2. R. Chemaly
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Correspondence to R. Chemaly.

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Informed consent was obtained from all individual participants included in the study.

Statement of Human and Animal Rights

The study has been approved by the appropriate institutional and/or national research ethics committee and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

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Al Hajj, G., Chemaly, R. Fistula Following Laparoscopic Sleeve Gastrectomy: a Proposed Classification and Algorithm for Optimal Management. OBES SURG 28, 656–664 (2018). https://doi.org/10.1007/s11695-017-2905-1

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  • DOI: https://doi.org/10.1007/s11695-017-2905-1

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