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Belluzzi A, Sample JW, Marrero K, Tomey D, Puvvadi S, Sharma I, Ghanem OM. Rare Complications Following Laparoscopic Sleeve Gastrectomy. J Clin Med 2024; 13:4456. [PMID: 39124722 PMCID: PMC11313060 DOI: 10.3390/jcm13154456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/26/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024] Open
Abstract
Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.
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Affiliation(s)
- Amanda Belluzzi
- Department of Surgery, Mayo Clinic, Rochester, MN 55095, USA; (A.B.); (J.W.S.)
- Department of Surgery, Rovigo Hospital, 45100 Rovigo, Italy
| | - Jack W. Sample
- Department of Surgery, Mayo Clinic, Rochester, MN 55095, USA; (A.B.); (J.W.S.)
| | - Katie Marrero
- Carle Foundation Hospital General Surgery Residency, Champaign, IL 61801, USA
| | - Daniel Tomey
- Department of General Surgery, Houston Methodist Hospital, Houston, TX 77030, USA;
| | - Suraj Puvvadi
- College of Health Solutions, Arizona State University, Phoenix, AZ 85004, USA
| | - Ishna Sharma
- St. Peter’s Health Partners Bariatric and Metabolic Care, Albany, NY 12208, USA;
| | - Omar M. Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55095, USA; (A.B.); (J.W.S.)
- Division of Metabolic and Abdominal Wall Reconstructive Surgery, Mayo Clinic, Rochester, MN 55095, USA
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Ortiz Gómez JE, Toledo Barranco M, Medina Aguirre W, Guzmán Barba JA, Esparza Estrada I, Ruiz Cota P, Orozco Álvarez Malo JO. Management of gastropleural leak by video-assisted thoracoscopy after sleeve gastrectomy. J Surg Case Rep 2023; 2023:rjad479. [PMID: 37621955 PMCID: PMC10447076 DOI: 10.1093/jscr/rjad479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/05/2023] [Indexed: 08/26/2023] Open
Abstract
Obesity is a major public health issue with various comorbidities. Sleeve gastrectomy has become a popular treatment for obesity, but it carries the risk of complications, particularly staple line leakage. This case study focused on a 32-year-old woman with grade II obesity and hiatal hernia who underwent laparoscopic sleeve gastrectomy. Four days after surgery, she presented with abdominal pain, revealing leakage from the gastric sleeve into the thoracic cavity. Diagnostic procedures and interventions were performed, including cavity lavage, drainage placement, and stent placement. The patient showed clinical improvement after video-assisted thoracoscopic surgery and a multidisciplinary approach involving nutrition support and antibiotics. Despite the challenges, the patient's clinical course improved, leading to discharge with no evidence of leakage on follow-up endoscopy. Careful monitoring and timely interventions are essential to manage complications in sleeve gastrectomy procedures and ensure optimal patient outcomes.
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Affiliation(s)
- Jesús Elías Ortiz Gómez
- Elias Ortiz & Company Mexico Weight Loss Specialists, Bariatric Surgery Department, Ernesto Sarmiento 2308, Tijuana, Baja California 22046, Mexico
- Colegio de Cirujanos Bariatras y Enfermedades Metabólicas del Estado de Baja California, Tijuana, Baja California 2050, Mexico
| | - Mario Toledo Barranco
- Elias Ortiz & Company Mexico Weight Loss Specialists, Bariatric Surgery Department, Ernesto Sarmiento 2308, Tijuana, Baja California 22046, Mexico
| | - Willberto Medina Aguirre
- Elias Ortiz & Company Mexico Weight Loss Specialists, Bariatric Surgery Department, Ernesto Sarmiento 2308, Tijuana, Baja California 22046, Mexico
| | - José Aldo Guzmán Barba
- Elias Ortiz & Company Mexico Weight Loss Specialists, Bariatric Surgery Department, Ernesto Sarmiento 2308, Tijuana, Baja California 22046, Mexico
| | - Isaac Esparza Estrada
- Elias Ortiz & Company Mexico Weight Loss Specialists, Bariatric Surgery Department, Ernesto Sarmiento 2308, Tijuana, Baja California 22046, Mexico
| | - Patricia Ruiz Cota
- Elias Ortiz & Company Mexico Weight Loss Specialists, Bariatric Surgery Department, Ernesto Sarmiento 2308, Tijuana, Baja California 22046, Mexico
| | - José Oscar Orozco Álvarez Malo
- Colegio de Cirujanos Bariatras y Enfermedades Metabólicas del Estado de Baja California, Tijuana, Baja California 2050, Mexico
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3
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Mongardini FM, Cacciatore C, Catauro A, Maglione F, Picardi F, Lauro A, Gambardella C, Allaria A, Docimo L. Stemming the Leak: A Novel Treatment for Gastro-Bronchial Fistula. Dig Dis Sci 2022; 67:5425-5432. [PMID: 36251132 DOI: 10.1007/s10620-022-07711-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 01/05/2023]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is a commonly used procedure in bariatric patients that often has excellent results. Despite its advantages, LSG is burdened by specific intraoperative and postoperative early and late complications. One of the life-threatening complications is gastric fistula, usually treated with a multidisciplinary surgical-endoscopic approach. In case of failure of the latter, alternative nonoperative techniques such as the use of autologous stem cells truly represents an innovative possibility, with only few cases described in literature. Here, we report the case of a 25-year-old man with post-LSG broncho-gastric fistula treated with application of autologous stem cells after the failure of the conventional surgical/endoscopic approach.
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Affiliation(s)
- F M Mongardini
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - C Cacciatore
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Catauro
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - F Maglione
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - F Picardi
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Lauro
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy.,Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - C Gambardella
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Allaria
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - L Docimo
- General, Mini-invasive, Oncological and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
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Chao S, Hoch V, Gilbert T, Nelson S, Sheetz K, Ghaferi A, Wakeam E, Co I. A 44-Year-Old Woman with Dyspnea and Hemoptysis in the Setting of Remote Bariatric Surgery. Chest 2022; 162:e173-e176. [PMID: 36210110 PMCID: PMC9633809 DOI: 10.1016/j.chest.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/14/2022] [Accepted: 05/12/2022] [Indexed: 11/05/2022] Open
Abstract
CASE PRESENTATION A 44-year-old woman was transferred to the ED from an outside hospital because of hemoptysis and concern for left-sided pulmonary infiltrate with associated pleural effusion. The patient presented to this outside hospital multiple times over the past 3 months because of left-sided shoulder pain, diffuse myalgias, and supraventricular tachycardia. On her third visit, she was found to have a left-sided pleural effusion and underwent diagnostic and therapeutic thoracentesis; 1.5 L of fluid was removed. Fluid studies reportedly demonstrated an exudative pleural effusion with negative bacterial cultures and no evidence of neoplastic process. The patient was referred to the Rheumatology Department by the outside hospital for suspected underlying autoimmune process. In the months leading up to her current presentation, the patient had been prescribed one prednisone burst and two prednisone tapers. She was then placed on a regimen of 10 mg prednisone daily and 200 mg hydroxychloroquine bid by her primary care doctor. This was tapered by the Rheumatology Department such that the patient was on 7.5 mg of prednisone daily on arrival to this ED. Rheumatologic workup until this point revealed only low titer (1:80) positive antinuclear antibody. Prior to these ED visits, the patient had been otherwise healthy with only a history of a Roux-en-Y gastric bypass 17 years earlier. Aside from recent daily low-dose prednisone use, the patient did not have other preexisting immune compromise or risk factors for aspiration such as seizure disorder, chronic alcohol use, or cognitive impairment. Before her transfer, the patient experienced foul-smelling, maroon-colored hemoptysis as well as anemia that required a higher level of care. On arrival to the ED, she was in acute hypoxic respiratory failure. The patient was intubated emergently and was admitted to the medical critical care unit for further treatment.
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Affiliation(s)
- Samantha Chao
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI.
| | - Victoria Hoch
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Timothy Gilbert
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI
| | - Sarah Nelson
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kyle Sheetz
- Department of Surgery, Section of Transplantation, University of California San Francisco, San Francisco, CA
| | - Amir Ghaferi
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Elliot Wakeam
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI
| | - Ivan Co
- Department of Emergency Medicine and Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI
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Abstract
PURPOSE Laparoscopic sleeve gastrectomy (LSG) is estimated to be its most severe complication. An aggressive management with surgical reconstructive procedures can be proposed in patients in whom all the conservative endoscopic techniques fail. The purpose of the present study was to report our experience with Roux-en-Y gastric bypass (RYGBP) as treatment for the chronic leak after LSG. METHODS Between January 2013 and July 2019, 17 consecutive patients underwent RYGBP for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach and the definitive surgical repair were carefully reviewed. RESULTS Seventeen patients (13 women) with a median age of 39 years (24-67) with a median body mass index (BMI) of 40 kg/m2 (30-52) underwent RYGBP for persistent fistula. Sixteen patients had their early LSG performed in another hospital. Eleven patients had an initial endoscopic treatment by pigtail drains following laparoscopic drainage and 6 other patients had the endoscopic stent as the first-choice line treatment. The overall average fistula diagnosis was done at 7.7 months (2-49 months) for 12 patients. For the rest of five patients, the procedure was performed almost in the acute setting (< 30 days). All procedures were performed by laparotomy but one. Five patients had a gastrojejunal anastomosis leak diagnosed by salivary flow in the drainage, but all patients were treated conservatively. No post-operative mortality was recorded. CONCLUSIONS Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience, RYGBP approach including the leak site offers a low morbidity rate.
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Shoar S, Hosseini FS, Gulraiz A, Ikram W, Javed M, Naderan M, Shoar N, Modukuru VR. Intrathoracic gastric fistula after bariatric surgery: a systematic review and pooled analysis. Surg Obes Relat Dis 2020; 17:630-643. [PMID: 33334678 DOI: 10.1016/j.soard.2020.10.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 01/06/2023]
Abstract
Even in the hands of highly experienced bariatric surgeons, perioperative complications are inevitable. Of these, leaks and fistulas are amongst the scariest complications. Intrathoracic gastric fistulas (ITGF) can be associated with serious morbidity, mostly when cases are misdiagnosed or detected with delay. This is a systematic review of the literature to investigate the clinical and surgical outcomes of morbidly obese adult patients with a confirmed diagnosis of ITGF following bariatric surgery. A pooled analysis of 25 articles, encompassing 76 patients with post-bariatric ITGF, showed that the clinical outcome depends on the initial presentation, timing of the diagnosis in relation to symptom onset, and prompt and effective treatment. Any septic or unstable patient must undergo urgent surgical intervention, while stable patients might tolerate a step-up approach and watchful waiting for nonsurgical treatment. Among those who undergo surgery, treatment failure and the mortality rate are substantially high. Contingent upon a prompt management strategy, patients with postbariatric ITGF can generally have a favorable outcome in the long term.
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Affiliation(s)
- Saeed Shoar
- Department of Clinical Research, ScientificWriting Corp, Houston, TX.
| | | | - Azouba Gulraiz
- Faculty of Medicine, Nishtar Medical University, Multan, Pakistan
| | - Waleed Ikram
- Faculty of Medicine, Lahore Medical and Dental College, Lahore, Pakistan
| | - Moiz Javed
- Faculty of Medicine, Lahore Medical and Dental College, Lahore, Pakistan
| | - Mohammad Naderan
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Shoar
- Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Venkat R Modukuru
- Department of Surgery, Metropolitan Hospital Center, New York Medical College, New York, NY
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Sakran N, Zakeri R, Madhok B, Graham Y, Parmar C, Mahawar K, Pouwels S. Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options. Obes Surg 2020; 31:357-369. [PMID: 33123868 DOI: 10.1007/s11695-020-05078-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/31/2022]
Abstract
This study aimed to establish the optimal diagnostic and treatment algorithm for the management of gastric fistula in the chest (GFIC) after sleeve gastrectomy (SG) through a systematic review of published cases. A multi-database search was performed, which produced 1182 results, of which 26 studies were included in this systematic review. The initial presentation included subphrenic collections, leaks, or (recurrent) pneumonia with associated symptoms such as persistent cough, fever, and/or dyspnea. Computed tomography (CT) scan in combination with either upper gastrointestinal (UGI) series or an esophagogastroduodenoscopy (EGD) was used to adequately diagnose the fistulas. Initial treatment was either with clips and/or clips and stents that were placed endoscopically. When unsuccessful in the majority of the cases, the surgical treatment consisted of total gastrectomy and Roux-en-Y esophagojejunostomy in a laparoscopic or open fashion.
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Affiliation(s)
- Nasser Sakran
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel. .,The Technion - Israel Institute of Technology, Haifa, Israel.
| | - Roxanna Zakeri
- Department of Surgery, University College London Hospital NHS Foundation Trust, London, UK
| | - Brijesh Madhok
- University Hospital of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Yitka Graham
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.,Facultad de Psucologia, Universidad Anahuac Mexico, Mexico City, Mexico.,Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | | | - Kamal Mahawar
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.,Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Taleb S, Nedelcu M, Skalli M, Loureiro M, Nedelcu A, Nocca D. The evolution of surgical treatment for chronic leak following sleeve. Surg Obes Relat Dis 2020; 17:278-283. [PMID: 33218903 DOI: 10.1016/j.soard.2020.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/15/2020] [Accepted: 10/02/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Leak is estimated to be the most severe complication of laparoscopic sleeve gastrectomy (LSG), with sporadic failure of endoscopic techniques. In such cases, an aggressive management with surgical reconstructive procedures can be proposed to patients in whom all the conservative endoscopic techniques failed. OBJECTIVES The purpose of the present study was to report our experience with surgical approach for the treatment of chronic leak after LSG. SETTING University hospital, France. METHODS Between January 2013-December 2019, 21 consecutive patients underwent reconstructive surgery for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach, and the definitive surgical repair were carefully reviewed. RESULTS Twenty-one patients (17 women) with a mean (standard deviation [SD]) age of 42.7 years (9.81) and a mean (SD) body mass index (BMI) of 27.3 (5.2) kg/m2 underwent reconstructive surgery for persistent fistula. Seventeen patients (81%) had their early LSG performed in another hospital. Endoscopic treatment was represented by the pigtail drain or stent in 9 cases each, ovesco in 8 cases, and glue for 2 patients. The reconstructive surgery was performed within 6 months in 8 cases; between 6-12 months in 6 cases; between 1-3 years in 4 cases, and >3 years in 3 cases. There were 14 fistulo-jejunostomy (66.7%), 5 Roux-en-Y gastric bypass (23.8%), and 2 total gastrectomies (9.5%). The operative time was between 99 minutes and 5.5 hours (mean = 216.2, median = 225 min). The hospital stay ranged from 5-30 days (mean = 12.67, median = 11 d) and the surgical reintervention rate was 23.8% (5/21 patients), including 1 case of recurrent hemorrhage requiring 3 surgical operations over 1 month of postoperative follow-up. No postoperative mortality was recorded. CONCLUSIONS Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience the fistulo-jejunostomy approach shows a low morbidity rate. (Surg Obes Relat Dis 2020;17:278-283.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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Affiliation(s)
| | - Marius Nedelcu
- ELSAN, Clinique Bouchard, Marseille, France; ELSAN, Clinique Saint Michel, Toulon, France.
| | | | - Marcelo Loureiro
- CHU de Montpellier, Montpellier, France; University Montpellier 1, Montpellier, France; Universidade Positivo, Curitiba, Brazil
| | | | - David Nocca
- CHU de Montpellier, Montpellier, France; University Montpellier 1, Montpellier, France
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Anatomical Relations Between the Esogastric Junction, the Diaphragm, the Pleura, and the Left Lung in Chronic Esogastro-bronchial and/or Esogastro-pleural Fistulas After Sleeve Gastrectomy. Obes Surg 2020; 29:2814-2823. [PMID: 31069692 DOI: 10.1007/s11695-019-03912-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Gastric fistula is a severe complication following sleeve gastrectomy (SG). Chronic gastric fistula can progress to complex anatomical situations, such as esogastro-bronchial and/or esogastro-pleural (EGBP) fistulas. We decided to analyze the anatomical characteristics of these EGBP fistulas after SG. METHODS Our work consisted of an analysis of the clinical, endoscopic, and radiological data of patients treated for EGBP fistulas after SG at the Georges Pompidou European Hospital from May 2009 to November 2017. RESULTS A total of 11 patients were retrospectively included with available complete clinical, endoscopic, and radiological data. The origin of the fistula was mostly at the top of the staple line. The fistula's termination was pleural in 5 patients (45%) and bronchial in 6 (55%). In bronchial fistulas, 2 were proximal and 4 were distal, with the left pulmonary posterolateral segment (S10) being reached in each case. The trans-diaphragmatic passage was through the left cupola in 9 out of 11 patients (82%). In 2 patients, the passage was trans-hiatal (18%). Interestingly, the 2 eso-bronchial fistulas had a trans-hiatal passage with a termination in the proximal bronchus, while the 4 gastro-bronchial fistulas had a trans-diaphragmatic passage with a termination in the distal bronchus. All pleural fistulas were gastric with a trans-diaphragmatic passage. CONCLUSIONS Esogastro-bronchial and gastro-pleural fistulas after SG originated mostly at the top of the staple line. Eso-bronchial fistulas had a trans-hiatal passage with a proximal bronchial termination, while gastro-bronchial fistulas had a trans-diaphragmatic passage with a distal bronchial termination.
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Diaz R, Welsh LK, Perez JE, Narvaez A, Davalos G, Portenier D, Guerron AD. Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy: Meeting presentations: Digestive Disease Week 2019. Endosc Int Open 2020; 8:E70-E75. [PMID: 31921987 PMCID: PMC6949161 DOI: 10.1055/a-1027-6888] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. Leaks are the most feared complications after this procedure. Endoscopic septotomy has been described as a resolution technique that could be useful in the setting of late and chronic leaks. We present our experience in the management of gastric leaks with this advanced endoscopic technique. Patients and methods Retrospective review of patients who have been admitted to our hospital from January 2016 to December 2018. Results Five patients were found. All had their index surgery in outside hospitals. The average age was 51 years (range 40 - 69), and four patients were female. Mean time from LSG to leak presentation was 15 days (range 7 - 25). Mean time from leak presentation to septotomy procedure was 61 days (range 21 - 110). All patients were treated with sleeve dilatation before septotomy using endoscopic achalasia balloons. Mean procedure time was 79 minutes (range 55 - 125). Success was achieved in 80 % of patients, and no complications related to the procedure were identified. One patient underwent total gastrectomy for definitive management. Mean follow-up time was 14.25 months (range 6 - 26), and the average time for fistula closure was 60.25 days. Conclusion Endoscopic septotomy is safe and effective for management of chronic leaks after LSG. Associated non-selective dilatation may be a crucial step to allow distal patency and axis rectification for appropriate leak closure.
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Affiliation(s)
- Ramon Diaz
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Leonard K. Welsh
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Juan Esteban Perez
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Andres Narvaez
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Gerardo Davalos
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Dana Portenier
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - A. Daniel Guerron
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
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Alharbi A, Alnaami M, Alsayyari A, Almuhaideb M. Mini gastric bypass for the management of gastrobronchial fistula: A case report. Int J Surg Case Rep 2019; 66:192-195. [PMID: 31864149 PMCID: PMC6928340 DOI: 10.1016/j.ijscr.2019.11.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/12/2019] [Accepted: 11/30/2019] [Indexed: 01/06/2023] Open
Abstract
Gastrobronchial fistula is uncommon with an ambiguous presentation. It should be suspected among patients who underwent bariatric surgery. Optimal management is yet to be determined.
Introduction With the high rates of obesity worldwide, laparoscopic sleeve gastrectomy (LSG) has become a very popular procedure. Due to its simple technique, rare complications might be overseen. Gastric leaks and fistula are fairly uncommon complications. In comparison to other types of fistulas, gastrobronchial fistulas are rarer with serious complications. Definitive management is yet to be determined. We intend to explore the literature on the management approach of such patients. Presentation of case A 46-year-old male, presented with on/off abdominal pain, productive cough, and vomiting. The patient had left sided rhonchi on examination. In addition to a history of laparoscopic sleeve gastrectomy (LSG) 4 years ago. Imaging confirmed the presence of a gastrobronchial fistula. Conservative and endoscopic treatment failed. Consecutively, surgery was indicated. A laparoscopic mini gastric bypass with refashioning of gastric fistula edges and closure with graham patch was done. Conclusion Given the increasing number of such surgeries performed the recognition of acute and chronic complications, and their optimal management is of great importance. Although performing a Roux-en-Y fistulojejunostomy was recommended in the literature, conservative and endoscopic treatment should be considered before.
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Affiliation(s)
- Abdulhamid Alharbi
- Department of Surgery, King Khalid University Hospital, P.O. Box 7805 #37, Riyadh, 11472, Saudi Arabia.
| | - Mohammed Alnaami
- Department of Surgery, King Khalid University Hospital, P.O. Box 7805 #37, Riyadh, 11472, Saudi Arabia; College of Medicine, King Saud University, P.O. Box 7805 #37, Riyadh, 11472, Saudi Arabia.
| | - Abdulrahman Alsayyari
- College of Medicine, King Saud University, P.O. Box 7805 #37, Riyadh, 11472, Saudi Arabia.
| | - Mana Almuhaideb
- College of Medicine, King Saud University, P.O. Box 7805 #37, Riyadh, 11472, Saudi Arabia.
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12
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Surgical management for chronic leak following sleeve gastrectomy: Review of literature. Surg Obes Relat Dis 2019; 15:1844-1849. [DOI: 10.1016/j.soard.2019.03.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/18/2019] [Accepted: 03/10/2019] [Indexed: 12/11/2022]
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13
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Favere K, Vanderbiest K, Bresseleers J, Depuydt P. Benign gastrobronchial fistula following oesophagectomy in a patient presenting with respiratory failure. BMJ Case Rep 2019; 12:12/9/e228537. [PMID: 31488439 DOI: 10.1136/bcr-2018-228537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Benign gastrobronchial fistula (GBF) is a rare but potentially life-threatening complication of oesophagectomy for malignancy. We present a case of GBF post Ivor-Lewis surgery manifesting as pulmonary sepsis and type II respiratory failure. Clues to the diagnosis were persistent hypercapnia despite high minute ventilation, aspiration of gastric content through the endotracheal tube and accumulation of air in the nasogastric drainage bag. Flexible bronchoscopy confirmed the diagnosis. Surgical exploration identified necrosis of the proximal stomach as causative factor. Despite reconstruction of the oesophagogastric anastomosis and interposition of an intercostal muscle flap, the patient developed a new episode of type II respiratory failure. Bronchoscopy revealed in situ recurrence of the fistula. Patency of the fistula was proven through application of methylene blue with subsequent gastroscopy. A conservative, symptom-based, management was conducted. The patient died 6 hours later.
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Affiliation(s)
- Kasper Favere
- Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Klaas Vanderbiest
- Intensive Care Department, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Jan Bresseleers
- Intensive Care Department, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Pieter Depuydt
- Intensive Care Department, Universitair Ziekenhuis Gent, Gent, Belgium
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Shoja MM, Ansarin K. Conservative Management of a Delayed Benign Gastrobronchial Fistula: A 20-Year Follow-up. Cureus 2019; 11:e5444. [PMID: 31632889 PMCID: PMC6797007 DOI: 10.7759/cureus.5444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/20/2019] [Indexed: 12/11/2022] Open
Abstract
We describe a case of gastrobronchial fistula (GBF) following a thoracoabdominal gunshot wound in a previously healthy young man. Despite initial surgery, the patient suffered recurrent hemoptysis, and a GBF was diagnosed 18 months after initial presentation. The patient was treated with oral proton pump inhibitors for a prolonged period with the resolution of the fistula. During a follow-up 20 years later, no recurrence of the fistula was noted. The importance of early diagnosis of such fistulae cannot be overstated. This report provides a testimony to the feasibility of the conservative approaches in managing delayed, benign, and post-traumatic GBF.
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Affiliation(s)
| | - Khalil Ansarin
- Internal Medicine, Tabriz University of Medical Sciences, Tabriz, IRN
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15
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Abu Arab WS, Alqannas MH. Thoracic complications in bariatric surgery patients. Asian Cardiovasc Thorac Ann 2019; 27:573-583. [PMID: 31412709 DOI: 10.1177/0218492319870926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Obesity is a health issue that can lead to medical and psychological problems. Recently, bariatric surgery has become the best choice for treatment of selected candidates. As the number of bariatric surgeries increases, various related postoperative complications are being encountered. Most studies have been concerned with abdominal complications and thoracic complications were beyond their scope. The aim of this report was to review thoracic complications following bariatric surgery, in terms of incidence, management, and outcome. A literature search of English language published data concerning thoracic complications related to or following bariatric surgery was performed in November 2018. A total of 10,145 results were found. After screening titles and abstracts, 10,060 noneligible publications were excluded. Eighty-five publications were potentially eligible and their full texts were analyzed. After excluding overlapping series of patients, 44 studies were selected. These included 934 patients. Females accounted for 87.9% of the included patients. Ages ranged between 21 and 64 years (mean 43.86 ± 4.4 years). Most frequently encountered complications were esophageal (80.84%) followed by pulmonary (17.45%). The majority of esophageal complications were functional (82.38%) in contrast to the pulmonary type that were mostly organic (87.73%). There were 5 documented deaths. We concluded that thoracic complications are not infrequent after bariatric surgery. Esophageal and pulmonary are the most common thoracic complications reported. The outcome is usually favorable. Mortality may be avoided when complications are detected early and well-managed.
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Affiliation(s)
- Walid S Abu Arab
- 1 Thoracic Surgery Department, King Khalid Hospital, Najran, Saudi Arabia.,2 Cardiothoracic Surgery Department, University of Alexandria, Egypt
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16
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Cosse C, Rebibo L, Brazier F, Hakim S, Delcenserie R, Regimbeau JM. Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy. Br J Surg 2018; 105:570-577. [DOI: 10.1002/bjs.10732] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 09/12/2017] [Accepted: 09/20/2017] [Indexed: 01/30/2023]
Abstract
Abstract
Background
Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure.
Methods
Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis.
Results
One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure.
Conclusion
DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.
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Affiliation(s)
- C Cosse
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
- Institut National de la Santé et de la Recherche Médicale U1088, Jules Verne University of Picardie, Amiens, France
| | - L Rebibo
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - F Brazier
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - S Hakim
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - R Delcenserie
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - J M Regimbeau
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
- EA4294, Jules Verne University of Picardie, Amiens, France
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Role of Percutaneous Glue Treatment After Persisting Leak After Laparoscopic Sleeve Gastrectomy. Obes Surg 2017; 26:1378-83. [PMID: 26572526 DOI: 10.1007/s11695-015-1959-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Over the years, many treatment modes have been attempted for gastrocutaneous fistula (GCF) after laparoscopic sleeve gastrectomy (LSG). Minimally invasive techniques for GCF treatment include stent placement and radiological percutaneous glue treatment (GT). MATERIAL AND METHOD Ten patients underwent a radiological acrylate mixed with contrast medium GT combined or not with other treatment strategies such as relaparoscopy, ultrasound, or computerized tomography scan (CT scan)-guided drain and endoscopic stent placement. RESULTS Ten patients (mean age 47.1 years, range 64-29) were treated by percutaneous injection of glue after LSG leak. Body mass index (BMI) was 42.2 kg/m(2) ± 6.7 at the time of LSG surgery. Mean time between LSG and leak diagnosis was 12 days (range 4-31 days). GT was only effective when performed after endoscopic stent placement (80 % resolution). With this regimen, five patients required a laparoscopic Roux limb placement. All fistulas eventually healed a mean of 75 days (range 29-293 days) after GCF diagnosis. CONCLUSIONS Percutaneous glue treatment alone does not seem to provide adequate results. Stenting previous to the glue treatment allows for better results.
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Late gastrobronchial fistula postsleeve gastrectomy. Surg Obes Relat Dis 2017; 13:1088. [PMID: 28342680 DOI: 10.1016/j.soard.2017.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 02/16/2017] [Accepted: 02/16/2017] [Indexed: 11/20/2022]
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Affiliation(s)
- Allison R Schulman
- From Departments of Medicine (A.R.S., C.C.T., A.L.M., J.L.) and Surgery (A.T.), Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Ali Tavakkoli
- From Departments of Medicine (A.R.S., C.C.T., A.L.M., J.L.) and Surgery (A.T.), Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Christopher C Thompson
- From Departments of Medicine (A.R.S., C.C.T., A.L.M., J.L.) and Surgery (A.T.), Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Amy L Miller
- From Departments of Medicine (A.R.S., C.C.T., A.L.M., J.L.) and Surgery (A.T.), Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Joseph Loscalzo
- From Departments of Medicine (A.R.S., C.C.T., A.L.M., J.L.) and Surgery (A.T.), Brigham and Women's Hospital, Harvard Medical School, Boston
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Kassir R, Debs T, Blanc P, Gugenheim J, Ben Amor I, Boutet C, Tiffet O. Complications of bariatric surgery: Presentation and emergency management. Int J Surg 2016; 27:77-81. [DOI: 10.1016/j.ijsu.2016.01.067] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 01/10/2016] [Accepted: 01/21/2016] [Indexed: 01/05/2023]
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21
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Tabbara M, Polliand C, Barrat C. Gastrobronchial fistula: A rare complication of sleeve gastrectomy. J Visc Surg 2015. [DOI: 10.1016/j.jviscsurg.2015.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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22
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Gastrobronchial Fistula in Sleeve Gastrectomy and Roux-en-Y Gastric Bypass—A Systematic Review. Obes Surg 2015. [DOI: 10.1007/s11695-015-1822-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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23
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Guillaud A, Moszkowicz D, Nedelcu M, Caballero-Caballero A, Rebibo L, Reche F, Abba J, Arvieux C. Gastrobronchial Fistula: A Serious Complication of Sleeve Gastrectomy. Results of a French Multicentric Study. Obes Surg 2015; 25:2352-9. [DOI: 10.1007/s11695-015-1702-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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24
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Garcia-Quintero P, Hernandez-Murcia C, Romero R, Derosimo J, Gonzalez A. Gastropleural fistula after bariatric surgery: a report of two cases. J Robot Surg 2015; 9:163-6. [DOI: 10.1007/s11701-015-0505-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/17/2015] [Indexed: 11/28/2022]
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25
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Rebibo L, Dhahri A, Berna P, Yzet T, Verhaeghe P, Regimbeau JM. Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014; 10:460-7. [DOI: 10.1016/j.soard.2013.08.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 07/23/2013] [Accepted: 08/07/2013] [Indexed: 12/19/2022]
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Laparoscopic Roux limb Placement over a Fistula Defect Without Mucosa-to-Mucosa Anastomosis: a Modified Technique for Surgical Management of Chronic Proximal Fistulas After Laparoscopic Sleeve Gastrectomy. Obes Surg 2014; 24:825-8. [DOI: 10.1007/s11695-014-1217-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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27
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Gastrobronchial fistula as a late complication of sleeve gastrectomy. Surg Obes Relat Dis 2013; 9:e97-9. [DOI: 10.1016/j.soard.2013.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 04/14/2013] [Accepted: 04/15/2013] [Indexed: 11/21/2022]
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28
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van de Vrande S, Himpens J, El Mourad H, Debaerdemaeker R, Leman G. Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement. Surg Obes Relat Dis 2013; 9:856-61. [DOI: 10.1016/j.soard.2013.01.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 12/18/2012] [Accepted: 01/03/2013] [Indexed: 12/31/2022]
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