As laparoscopic sleeve gastrectomy (LSG) is nowadays the most popular bariatric procedure in the world, treatment options for managing complications, in particularly gastric leaks, are also emerging (1). Various treatment options for gastric leaks have been described. Key steps in the management of leaks are broad spectrum antibiotic therapy and prompt drainage of the extra-gastric collection, which can be performed by surgical, percutaneous, or endoscopic approaches. Conventional surgical management consisting of relaparoscopy with peritoneal lavage and external drainage is indicated in case of unstable patients with diffuse peritonitis. Nevertheless, further complementary treatment may be required and endoscopy has been proved to be a very valuable tool in our arsenal (2). Conservative endoscopic management with internal drainage, via double pigtail, is often successful for contained gastric leaks in hemodynamically stable patients (3). The success rate is higher when early diagnosis is made (4). Efficient internal drainage creates a favorable pressure gradient, allowing rapid mobilization and removal of external drainage, preventing the formation of a chronic fistula tract. Despite advances in the treatment of gastric leaks after bariatric surgical procedures, chronic leaks and fistula have been reported in the current literature (5,6). Chronic leaks are more challenging to treat due to their persistence (7,8). Treatment failure of these chronic complications is the case in some patients, needing further aggressive management to successfully address this issue once and for all.
A gastric leak after LSG should be considered chronic after 12 weeks and surgical management is then warranted, especially after failure of adequate endoscopic, radiologic and nutritional healing protocols (9). This type of leak will have a lining to the fistula tract and cavity, making it difficult to resolve without surgical intervention. Redo surgery can only take place after an optimal sepsis control and a thorough management of all nutritional deficiencies. Multiple treatment options have been proposed for managing chronic fistulas following LSG. Laparoscopic Roux-en-Y gastric bypass may promote fistula healing by relieving the pressure within the gastric tube (10). However, leaving the fistula tract in very high localization and additional stomach transection close to the inflamed fistula tract remain serious limitations of the approach. Total gastrectomy may treat the problem (11,12), but must be avoided as a first option because of subsequent cumbersome nutritional consequences and relatively high risk of complications related to the oesophago-jejunal anastomosis.
Finally, Roux-En-Y fistulo-jejunostomy (RYFJ) may be the preferred option for the treatment of such chronic gastric leaks or fistulas (Figure 1). It was first described by Baltasar et al. in 2007 (13) and it offers an option for completely controlling the fistula orifice while preserving the remnant gastric tube. Surgical technique has been previously described (14). A laparoscopic approach should be preferred when possible. The dissection of fibrotic adhesions and identification of the fistula orifice at the upper part of the gastric tube remain the most difficult parts of the procedure, leading to conversion in some cases. Dissection of the oeso-gastric junction is better carried out from right to left, using previously non-dissected planes to release and take down the distal third of the oesophagus. When the fistula orifice is isolated, debridement and removal of fibrotic scars is preferred to allow an anastomosis on healthy tissue. Roux limb anastomosis is then performed and a drainage is placed around the fistulo-jejunostomy for postoperative surveillance.
There are numerous other reports describing RYFJ technique and results. Vilallonga et al. presented the safety and efficacy of such an approach in 18 patients with chronic fistulas, with a mean length of hospital stay of 18.4 days (15). Chouillard et al. presented one of the largest series including 21 patients, showing satisfactory fistula control and postoperative results (16). A more recent work reported very good mid-term results, suggesting the durability of fistula healing and weight control (17). The recently published paper by Amor et al. (18) illustrates in the best way the success of LRYFJ for the treatment of chronic fistula after LSG, stretching the safety and effectiveness of this approach. In addition, we fully agree with the authors concluding that it remains a technically challenging procedure that should be reserved to specialized centers.
In conclusion, laparoscopic RYFJ seems to be a good surgical option for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons. Careful patient selection is essential since this approach should only be considered in patients with adequate nutritional status and after failure of a well conducted endoscopic management.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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