Management of Type 2 Late Sleeve Leak by Laparoscopic Suturing and Conversion to Roux-en-Y Gastric Bypass: Video Report

Abstract

Background: Laparoscopic sleeve forming gastrectomy (SFG) is a commonly performed bariatric procedure for the surgical management of morbid obesity. Staple line gastric leaks occur infrequently but are the most feared complication causing prolonged morbidity (Burgos et al., Obes Surg 19(12):1672–7, 2009; Márquez et al., Obes Surg 20(9):1306–11, 2010). Roux-en-Y diversion is an accepted management (Baltasar et al., Surg Obes Relat Dis 4(6):759–63, 2008). The aim of this video was to demonstrate the operative management of a late sleeve leak by laparoscopic suturing & conversion to a RYGB. Methods: We present the case of an 18-year-old woman with a BMI of 44.68 kg/m2 with hypothyroidism and polycystic ovarian disease who underwent laparoscopic sleeve gastrectomy and presented with a leak on postoperative day 13. She was diagnosed to have a type 2, late leak just beyond the esophagogastric junction (Csendes et al., Hepatogastroenterology 37 Suppl 2:174–7, 1990) Results: In this multimedia high-definition video, we present step-by-step the operative management of a late sleeve leak by laparoscopic suturing and conversion to a RYGB. 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, gastrojejunal anastomosis and jejuno-jejunal anastomosis. Drainage of fistula gradually decreased with absence of a leak on imaging in 12 days. This patient was diagnosed with a gastric sleeve leak on the 13th postoperative day, and the time to fistula closure from diagnosis was 1 month. Conclusions: Sleeve leak fistula repair with conversion to a RYGB aids healing by providing surgical decompression and better drainage. It may be considered as an alternative management technique in sleeve leaks.