title: Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms.
abstract: BACKGROUND
  Gastric fistula (GF) is the most serious complication after longitudinal sleeve gastrectomy (LSG), with an incidence ranging from 0 to 5 %. In this context, concomitant upper gastrointestinal bleeding (UGIB) has never been described. Here, we describe our experience of this situation and suggest a procedure for the standardized management of this life-threatening complication.
  
  
  METHODS
  We retrospectively analyzed all patients having been treated for post-LSG UGIB in our university medical center between November 2004 and February 2012. Data on GF and UGIB (time to onset, diagnosis and management) were assessed.
  
  
  RESULTS
  Forty patients were treated for post-LSG GF in our institution, 18 of whom (45 %) had been referred by tertiary centers. Four patients presented UGIB (10 %): two had undergone primary LSG, one had undergone simultaneous gastric band removal and LSG, and one had undergone repeat LSG. The median time interval between GF and UGIB was 15 days. The four cases of UGIB included three pseudoaneurysms (75 %, with two affecting the left gastric artery and one affecting the upper pole of the splenic artery) and one case of bleeding related to stent-induced gastric ulceration. Computed tomography enabled diagnosis of the pseudoaneurysm in all cases. Two of the four patients (50 %) were treated with selective embolization during arteriography, and two (50 %) were treated surgically with arterial ligation. One of the surgically treated patients died during follow-up.
  
  
  CONCLUSIONS
  UGIB after LSG was investigated in the context of a postoperative GF and was found to have been caused by a pseudoaneurysm in 75 % of cases. When looking for a pseudoaneurysm, a primary angiography should be preferred to endoscopy allowing selective arterial embolization in hemodynamically stable patients, whereas surgery should be reserved for treatment failures or hemodynamically instability.
authors: Department of Digestive Surgery, Amiens University Medical Center and University of Picardie Jules Verne, Amiens, France.
authors: Lionel
authors: L
authors: Rebibo
authors: David
authors: D
authors: Fuks
authors: Christelle
authors: C
authors: Blot
authors: Brice
authors: B
authors: Robert
authors: Pierre-Olivier
authors: PO
authors: Boulet
authors: Abdennaceur
authors: A
authors: Dhahri
authors: Pierre
authors: P
authors: Verhaeghe
authors: Jean-Marc
authors: JM
authors: Regimbeau
mesh_terms: D000328:Adult; D017541:Aneurysm, False / Q000150:complications* / Q000175:diagnosis; D000792:Angiography; D003937:Diagnosis, Differential; D004621:Embolization, Therapeutic / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D005747:Gastric Fistula / Q000150:complications* / Q000175:diagnosis; D024405:Gastroepiploic Artery; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D015391:Gastroplasty / Q000009:adverse effects*; D005773:Gastroscopy; D006801:Humans; D010535:Laparoscopy; D008026:Ligation; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011379:Prognosis; D012189:Retrospective Studies
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