Total Gastrectomy after Endotherapy Failure for Management of Chronic Gastric Leakage from Sleeve Gastrectomy: the End of a Nightmare

Obesity is a complex and multifactorial disease that is increasing worldwide. It has an important socio-economic impact and it led to the widespread use of bariatric surgery procedures. Laparoscopic sleeve gastrectomy is currently the most widely performed procedure. Possible postoperative complications are bleeding, abscess, strictures and nutrient deficiency, but the most dreaded one is gastric leakage. It may occur along the staple line, mostly in the upper third, with an incidence rate that ranges between 1% to 7%, and it may be burdened by additional morbidity and mortality. The management of leakage after laparoscopic sleeve gastrectomy is challenging, resource intensive and involves multiple professionals including surgeons, endoscopists, interventional radiologists and nutritionists. A standardized treatment protocol is still missing. Several conservative strategies are currently proposed to treat gastric leakage, including surgical or percutaneous drainage, double-pigtail stent, leakage site clipping and partially or fully covered self-expandable stents and naso-jejunal tube for enteral feeding. However, when all conservative techniques fail and the fistula becomes chronic, the only chance of resolution relies on radical surgery. This case report describes the case of a young woman who underwent laparoscopic sleeve gastrectomy for morbid obesity with no comorbidities. Thirty-nine days after the procedure, the patient developed a gastric leakage that later became chronic, persisting for more than two years. After failure of several different conservative treatment modalities, resolution was eventually obtained by radical surgery.