Non-conservative surgical management of chronic fistula after sleeve gastrectomy

Sleeve gastrectomy (SG) is the most widely performed bariatric operation in France (58.5% in 2016) and worldwide [1,2]. The technique is popular because of its technical simplicity [3], and it offers results that are similar to those observed after Roux-en-Y gastric bypass (RYGB) in terms of weight-loss and improvement of associated co-morbidities [4,5]. Postoperative complications are increasingly rare but remain potentially severe, particularly because of leakage (prevalence currently less than 1%) [6]. Treatment modalities depend on the interval from surgery to onset as well as the clinical status of the patient [7,8]. Persistent or chronic leakage is defined as leakage lasting more than four months; beyond this delay, endoscopic treatment becomes futile and deleterious [9]. Optimization of nutritional status and early endoscopic management are factors that can limit the persistence of leakage [10]. In case of chronic leakage, surgical treatment, preceded by correction of nutritional disorders, is the only therapeutic option [11]. Depending on the site of leakage and local conditions, fistulo-jejunostomy, RYGB or total gastrectomy can be proposed. Total gastrectomy, the least morbid solution, is the technique most often reported in the literature (57%) [11]. However, inflammation related to the leak and potential fistulous involvement of adjacent organs (pleura, bronchus, colon, spleen, or atmospheric) and retraction of the esophagus, pancreas and spleen are risk factors for complex operations; laparotomy is often necessary. Robotic-assisted surgery is a promising technique but publications are limited to case reports [12,13]. The goals of this work are to describe the surgical anatomy of chronic leakage after SG and to define the essential steps of total gastrectomy in this indication.