title: Laparoscopic Roux En Y Esophago-Jejunostomy for Chronic Leak/Fistula After Laparoscopic Sleeve Gastrectomy.
abstract: BACKGROUND
  Leak following laparoscopic sleeve gastrectomy (LSG) is one of the most serious and devastating complications. Endoscopic stents can treat most early LSG leaks, but is not as effective for chronic LSG leaks/fistulae. The surgical options to treat a chronic leak/fistula after LSG are laparoscopic Roux en Y esophago-jejunostomy (LRYEJ) or laparoscopic Roux en Y fistulo-jejunostomy.
  
  
  METHODS
  We reviewed our prospective database for all patients with leak after LSG treated with LRYEJ. We have described our algorithm for managing LSG previously. We prefer to optimize the nutritional status of patients with enteral rather than parenteral nutrition and drain all collections prior to LRYEJ.
  
  
  RESULTS
  We have treated four patients utilizing our technique of LRYEJ. Initial endoscopic stent placement was attempted in all four patients (two failed to resolve (50 %) and two had distal stenosis at the incisura not amenable to endoscopic stenting). We utilized enteral feeding through either naso-jejunal (NJ) or jejunostomy tube feeding in 3/4 (75 %) of patients, and in one patient with stenosis, we could not introduce a NJ tube endoscopically due to tight stricture. This patient was placed on total parenteral nutrition (TPN) and went on to develop pulmonary embolism. None of the patient developed leak after LRYEJ. The only patient with stenosis (25 %) had antecolic LRYEJ. In contrast, all patients who had retrocolic LRYGB laparoscopically did not develop stenosis.
  
  
  CONCLUSIONS
  Laparoscopic Roux en Y esophago-jejunostomy for chronic leak/fistula after is safe and effective. Preoperative enteral nutrition is important.
authors.affiliation: ACGME-I accredited Surgery Residency Program, Abu Dhabi, United Arab Emirates.
authors.forename: Maysoon
authors.initials: M
authors.lastname: Mahmoud
authors.affiliation: Bariatric and Metabolic Institute Abu Dhabi, Department of Surgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Maasher
authors.affiliation: Bariatric and Metabolic Institute Abu Dhabi, Department of Surgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Al Hadad
authors.affiliation: Bariatric and Metabolic Institute Abu Dhabi, Department of Surgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.
authors.forename: Elnazeer
authors.initials: E
authors.lastname: Salim
authors.affiliation: Bariatric and Metabolic Institute Abu Dhabi, Department of Surgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates. Nimeri@gmail.com.
authors.forename: Abdelrahman A
authors.initials: AA
authors.lastname: Nimeri
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000379:methods*; D004947:Esophagus / Q000601:surgery; D005402:Fistula / Q000209:etiology / Q000601:surgery*; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D007582:Jejunostomy / Q000379:methods*; D007583:Jejunum / Q000601:surgery; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011446:Prospective Studies; D012086:Reoperation / Q000379:methods; D016896:Treatment Outcome; D055815:Young Adult
keywords: Chronic leak/fistula laparoscopic Roux en Y esophago-jejunostomy; Laparoscopic sleeve gastrectomy; Morbid obesity