Sleeve to Colon Fistula: Laparoscopic Conversion to Roux-en-Y Gastric Bypass

Abstract

Laparoscopic sleeve gastrectomy (SG) remains the most common bariatric procedure performed in the USA [1]. Sleeve gastrectomy staple line leaks (SGL), despite being infrequent, are associated with mortality rates ranging from 0.14 to 0.4% [2, 3]. Although mortality rates are low, the insidious and refractory nature of SGLs contribute to the higher rate of morbidity associated with this complication. For the aforementioned reason, a high index of suspicion is required to properly diagnose and treat SGLs before subsequent damage (including fistulization) occurs. The anatomic location of upper gastrointestinal tract leaks and the close proximity to various abdominal or thoracic structures is a simple explanation to the increased risk of fistulization if these leaks are not diagnosed and treated early on [4, 5]. When SG fistulization occurs, and is detected at an early stage, endoscopic interventionmight be reasonable [6]. However, in chronic fistula cases, surgical re-intervention is almost always warranted. While various surgical modalities have been proposed including fistulectomy alone or conversion to Roux-en-Y gastric bypass [4, 7], no consensus on a single systematic approach is still present to this day. In wide diameter fistulas present in the upper third of the sleeve staple line or close to the gastroesophageal junction, gastrectomy with gastro-jejunostomy (GJ) or esophago-jejunostomy (EJ) is an effective way to mitigate the problem [4]. However, this approach itself is associated with increased morbidity [8]. In this report, we present a multimedia video of a sleeve to transverse colon fistula treated by a laparoscopic conversion to Roux-enY-gastric bypass (RYGB). Additionally, due to the involvement of the splenic hilum with the inflammatory process, the patient was consented and counseled on a potential laparoscopic splenectomy and given the vaccination regimen for asplenic patients in the preoperative setting.