Open total gastrectomy with Roux-en-Y reconstruction for a chronic fistula after sleeve gastrectomy

Abstract

Background: Surgery appears to be the best treatment option for a chronic fistula after laparoscopic sleeve gastrectomy (LSG). Conservative procedures (conversion into a Roux-en-Y gastric bypass, Roux-limb placement) have proven their feasibility and efficacy, but an open total gastrectomy (TG) is sometimes required in challenging situations.

Objectives: To assess outcomes from 12 consecutive patients who underwent surgery for a post-sleeve gastrectomy chronic fistula (PSGCF) between January 2004 and February 2012.

Setting: University public hospital, France.

Methods: Patients with a PSGCF who underwent surgery were included in this retrospective study. Mortality, morbidity (i.e., Clavien-Dindo score), weight loss, and nutritional status were assessed.

Results: Twelve of 57 patients (21%) with a post-LSG leak developed a PSGCF. There were 3 men (25%). Mean age was 39±9 years and mean preoperative body mass index was 35±5 kg/m². All 12 patients underwent an open total gastrectomy with an esojejunostomy (TG). Conservative procedures were considered but not possible. The mean follow-up period was 38±11 months. The mean delay between LSG and TG was 12±6 months. Intraoperative discovery of multiple (>2) gastric fistulas was reported in 9 patients (75%). There were no deaths, but morbidity rate was 50%. Early postoperative fistula occurred in 3 patients (anastomosis n = 1, duodenal stump n = 2). None of these patients required further surgery. The median healing time of the fistula was 37 days (range 24-53). Promising results from weight loss and nutritional status were found at the end of the follow-up.

Conclusion: A salvage open TG is a well-tolerated and reproducible salvage procedure for cases of a PSGCF, when conservative procedures are not possible.

Keywords: Chronic fistula; Gastric leakage; Morbid obesity; Sleeve gastrectomy; Total gastrectomy.