title: Management of Type 1 Late Sleeve Leak with Gastrobronchial Fistula by Laparoscopic Suturing and Conversion to Roux-en-Y Gastric Bypass: Video Report.
abstract: BACKGROUND
  Gastrobronchial fistula (GBF) is a rare but serious complication after laparoscopic sleeve gastrectomy (LSG). It commonly appears sometime after the primary LSG. (Alharbi Ann Thorac Med. 8(3):179-80, 2013; Albanopoulos et al. Surg Obes Relat Dis. 9(6):e97-9, 2013). Surgical approach is an effective treatment. (Rebibo et al. Surg Obes Relat Dis. 10(3):460-67, 2014). The aim of this video was to demonstrate the operative management of a gastrobronchial fistula after LSG by laparoscopic suturing and conversion to a Roux-en-Y gastric bypass (RYGB).
  
  
  METHODS
  We present the case of a 53-year-old woman, with a BMI of 50.2 who presented with a left lower lobe consolidation 7 months after LSG. Imaging revealed a gastrobronchial fistula with left lower lobe consolidation and small sub-diaphragmatic collections. Endoscopy done revealed a fistulous opening beyond the oesophago-gastric junction and a trial of endoscopic stenting failed.
  
  
  RESULTS
  In this multimedia high definition video, we present step-by-step the operative management of a late sleeve leak with gastrobronchial fistula by laparoscopic suturing and conversion to a RYGB. The procedure included mobilization of the gastric sleeve, identification and suturing of the fistulous opening, creation of a gastric pouch, creation of an ante-colic Roux limb, gastro-jejunal anastomosis and jejuno-jejunal anastomosis. Drainage of the fistula decreased with absence of a leak on imaging and pneumonia resolved in 15 days. This patient was diagnosed 7 months postoperatively with a gastric sleeve leak and the time to fistula closure from diagnosis was 2 months.
  
  
  CONCLUSIONS
  GBF is a severe complication of bariatric surgery that usually presents late in the postoperative period. GBF after LSG can be treated by surgical fistula repair and conversion of the sleeve into a RYGB.
authors.affiliation: Department of Bariatric Surgery, GEM Hospital and Research Centre, 45, Pankaja Mill Road, Coimbatore, 641045, India. praveenraj@me.com.
authors.forename: Palanivelu
authors.initials: P
authors.lastname: Praveenraj
authors.affiliation: Department of Bariatric Surgery, GEM Hospital and Research Centre, 45, Pankaja Mill Road, Coimbatore, 641045, India.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Gomes
authors.affiliation: Department of Bariatric Surgery, GEM Hospital and Research Centre, 45, Pankaja Mill Road, Coimbatore, 641045, India.
authors.forename: Saravana
authors.initials: S
authors.lastname: Kumar
authors.affiliation: Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India.
authors.forename: Palanisamy
authors.initials: P
authors.lastname: Senthilnathan
authors.affiliation: Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India.
authors.forename: Ramakrishnan
authors.initials: R
authors.lastname: Parthasarathi
authors.affiliation: Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India.
authors.forename: Subbiah
authors.initials: S
authors.lastname: Rajapandian
authors.affiliation: Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India.
authors.forename: Chinnusamy
authors.initials: C
authors.lastname: Palanivelu
mesh_terms: D057868:Anastomotic Leak / Q000601:surgery*; D001983:Bronchial Fistula / Q000209:etiology / Q000601:surgery*; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects*; D015390:Gastric Bypass; D005747:Gastric Fistula / Q000209:etiology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery
keywords: Bariatric surgery; Gastric sleeve leak; Gastrobronchial fistula; Morbid obesity; Sleeve gastrectomy