David Nguyen, MD, Fernando Dip, MD, LeShon Hendricks, MD, Emanuele Lo Menzo, MD, PhD, FACS, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS. Cleveland Clinic Florida
Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance as the preferred option for treating obesity. The risk of leak and subsequent fistula after a sleeve gastrectomy still present significant concerns in clinical practice. Considerable debate persists in the management and treatment of leaks after LSG. This current series present unusual fistulas post LSG and their surgical management.
The series presents chronic leaks that have progressed into fistulas. Three fistula cases are presented: gastrocolic, gastropleural, and gastrosplenic. The gastrocolic diagnosis involved surgical intervention and re-operation. Conventional management of nutritional support and drainage were used in the gastropleural and gastrosplenic cases. 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.
The postoperative courses were uneventful in the gastropleural and gastrosplenic cases. The patients were discharged home on postoperative Day 6 and Day 7 respectively. The gastrocolic patient had an extended postoperative hospital course with significant pleural effusion, congestive heart failure, and deep vein thrombosis. This patient was discharged home on postoperative Day 35. All cases were negative for anastomotic leaks. To date, the fistulas healed with no recurrence.
En-bloc resection of the fistula with subtotal gastrectomy and Roux-en-Y esophagojejunostomy is an effective option to treat chronic staple line leakage when conservative therapy is rendered ineffective. Adequate preoperative planning with optimization of nutritional status and control of local and systemic sepsis is paramount for the ultimate success. A symptomatic leak requires immediate operation regardless of the time interval between the primary sleeve operation and appearance of the leak.