title: The Surgical Management of Complex Fistulas After Sleeve Gastrectomy.
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.
authors.affiliation: The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA.
authors.forename: David
authors.initials: D
authors.lastname: Nguyen
authors.affiliation: The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA.
authors.forename: Fernando
authors.initials: F
authors.lastname: Dip
authors.affiliation: The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA.
authors.forename: LéShon
authors.initials: L
authors.lastname: Hendricks
authors.affiliation: The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Lo Menzo
authors.affiliation: The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Szomstein
authors.affiliation: The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA. ROSENTR@ccf.org.
authors.forename: Raul
authors.initials: R
authors.lastname: Rosenthal
mesh_terms: D000328:Adult; D057868:Anastomotic Leak / Q000209:etiology; D002908:Chronic Disease; D003108:Colonic Diseases / Q000209:etiology / Q000601:surgery; D013505:Digestive System Surgical Procedures; D005743:Gastrectomy / Q000009:adverse effects*; D005747:Gastric Fistula / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007412:Intestinal Fistula / Q000209:etiology / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D009765:Obesity / Q000601:surgery*; D010995:Pleural Diseases / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D016156:Respiratory Tract Fistula / Q000209:etiology / Q000601:surgery*; D013158:Splenic Diseases / Q000209:etiology / Q000601:surgery*; D055815:Young Adult
keywords: Fistula; Gastrocolic; Gastropleural; Gastrosplenic; Sleeve gastrectomy; Surgery