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A left thoracoabdominal approach for transdiaphragmatic fistulas following bariatric surgery
Author’s Accepted Manuscript A Left Thoracoabdominal Approach for Transdiaphragmatic Fistulas following Bariatric Surgery John S. Riley, Edmund K. Bartlett, Daniel T. Dempsey www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(17)30209-5 http://dx.doi.org/10.1016/j.soard.2017.04.022 SOARD3011
To appear in: Surgery for Obesity and Related Diseases Cite this article as: John S. Riley, Edmund K. Bartlett and Daniel T. Dempsey, A Left Thoracoabdominal Approach for Transdiaphragmatic Fistulas following Bariatric Surgery, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.04.022 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
TITLE: A Left Thoracoabdominal Approach for Transdiaphragmatic Fistulas following Bariatric Surgery
AUTHORS: John S. Riley, BA MSt1 Edmund K. Bartlett, MD2 Daniel T. Dempsey, MD1
AFFLIATIONS: [1] Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA [2] Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
SOURCES OF FUNDING: None.
CORRESPONDING AUTHOR: John S. Riley 3400 Spruce Street 4 Silverstein Pavilion Philadelphia, Pennsylvania 19104 [email protected] Telephone: (847) 302-5642 Fax: (215) 349-8195
SHORT TITLE: A Left Thoracoabdominal Approach For Fistulas
2
A Left Thoracoabdominal Approach for Transdiaphragmatic Fistulas following Bariatric Surgery
INTRODUCTION Transdiaphragmatic fistulas are a rare yet important long-term complication of bariatric surgery. While small fistulas can sometimes be managed endoscopically, large and complex fistulas usually require surgery.(1,2) The left thoracoabdominal approach, once used frequently in the treatment of surgical diseases of the distal esophagus, gastroesophageal junction, and upper stomach, has fallen out of favor in recent decades. In our experience, however, it remains useful for addressing complex transdiaphragmatic fistulas following bariatric surgery. The following case represents an instructive example.
CASE PRESENTATION AND MANAGEMENT Our patient is a 50 year old female with a history of multiple prior abdominal operations, most significantly a vertical banded gastroplasty (VBG) converted to sleeve gastrectomy (SG) five years prior to presentation. Thirteen months after the revision SG, she was involved in a motor vehicle accident that resulted in direct trauma to the left flank. Following this accident, she reported left-sided abdominal pain associated with nausea and constipation, and an abdominal CT demonstrated a large fluid collection adjacent to the gastric staple line, concerning for a leak. Conservative management with repeated percutaneous drainage was attempted but was ultimately unsuccessful, and she developed a chronic staple line leak complicated by a subphrenic abscess. Following a third attempt at percutaneous drainage 8 months prior to presentation, she developed left chest pain, shortness of breath, and a cough. A chest CT demonstrated a hydropneumothorax with suspected gastropleural fistula. Endoscopic stenting of the distal stomach and placement of a left thorocostomy tube failed to resolve her symptoms. On presentation to our center 6 months later, all percutaneous drains and the left chest tube had been removed. We ordered a CT with contrast and a contrast upper GI study (Figure 1), which demonstrated a persistent gastropleural fistula with associated phlegmon in the left chest. No VBG band was appreciated on the CT, as it had been removed at the time of SG conversion. A remnant of the stomach from the VBG to SG conversion or, less likely, a contained
3
extraluminal collection with peripheral pseudocapsule was noted at the superolateral aspect of the stomach, measuring 2.9 x 4.2 cm. Given the previous failures of conservative management, we elected definitive surgical management at this time. The patient’s BMI was 23.4, albumin 4.0 g/dL, and pre-albumin 22.9 mg/dL. Therefore we did not administer preoperative parenteral or enteral nutritional support.. A preoperative endoscopy was performed. The communication between the proximal stomach and the fundic segment was seen 42 cm from the incisors on the gastric side of the GE junction. The opening was approximately 1 cm in diameter, and purulent material was visualized beyond it.
Figure 1: (A) The preoperative chest CT. (B) The preoperative upper GI study; VBG vertical staple line (solid arrow), 1 cm opening (long dashed arrow) connecting the stomach lumen to the fundic segment, and origin of the gastropleural fistula (short dashed arrow). (C) The postoperative upper GI study with nasogastric tube in place; new TA staple line (solid arrow).
We began our operation with a left thoracoabdominal incision in the seventh interspace. The left costal margin was transected. The diaphragm was opened near the costal margin and the oblique muscles of the abdomen were opened in continuity with this. The diaphragm was then opened radially for a short distance. The peritoneum was entered, and we took down the splenic flexure of the colon. Above the spleen, tracking posteriorly, we identified a phlegmon that was in continuity with the apex of the fundus. We opened the fundus anteriorly, and we could see that it communicated with the main part of the stomach through a 1 cm opening around which we could see some staples. The apical fundus was mostly disconnected from the stomach by the previous VBG, but it was well-vascularized by two intact short gastric vessels. We opened the retropleural space posteriorly where the fistula tracked and decorticated the left lung. We dissected the fundus from the diaphragm and retroperitoneum, to which it was densely adherent. After freeing it up, it was only connected to the remaining stomach by the small opening described above. With a 38F Bougie in the esophagus and stomach, we then placed a TA 90 green stapler parallel to the long axis of the stomach to incorporate the previously-placed VBG vertical staple line and the opening into this somewhat isolated fundic segment. As the VBG band had been removed at the time of SG conversion, we were able to place the TA stapler just medial to the prior EEA stapled window without impediment. After performing an EGD, which demonstrated excellent patency of the cardia and an adequate lumen of the proximal stomach, we fired the TA stapler, excising the fundic segment (Figure 2). Air and methylene blue tests were negative. We then raised a well-vascularized omental pedicle flap, brought it up into the opening in the diaphragm, and used it to cover the staple line and fill the
4
subdiaphragmatic space. We placed a jejunostomy feeding tube, a Blake drain in the left upper quadrant, and two chest tubes in the left pleural space.
Figure 2: A diagram of the patient’s evolving anatomy. (A) VBG; gastric band (solid arrow) and vertical staple line (dashed arrow). (B) Converted to SG; EEA stapled window (solid arrow) and isolated fundic segment (dashed arrow). (C) Leak and fistula formation; 1 cm opening (solid arrow) from stomach lumen to fundic segment and origin of the gastropleural fistula (dashed arrow). (D) Excision of the fundic segment; new TA staple line (solid arrow).
Postoperatively the patient required 2 units of packed red cells. She was discharged on postoperative day 9 with her pain well-controlled on oral medications and tolerating bariatric clears with supplemental tube feedings. At her 1 month follow-up, she was tolerating a full liquid diet with occasional reflux but no nausea or vomiting. Her cough was markedly improved, and she reported resolution of her chronic chest pain and shortness of breath. At her 3 month followup, she was tolerating a regular diet without complaint.
DISCUSSION This case illustrates one of the recognized hazards of VBG to SG conversion, which requires care not to leave an isolated (or, as in this case, almost isolated) or devascularized segment of the fundus. Superior alternatives would have been excision of the fundus at the angle of His, which we later performed in our operation, or conversion to RYGB as described by Gonzales, et al.(3) It is unclear whether alternative revision would have prevented the staple line leak following trauma to the left flank, but the presence of the isolated fundic segment certainly complicated our dissection of the subsequent gastropleural fistula by its dense adherence to the diaphragm and retroperitoneum. It should also be noted, however, that the preservation of sufficient lumen of the proximal stomach by the index surgeon gave us the ability, at the time of our operation, to create a new staple line just medial to the vertical VBG staple line, thus obviating the need for total gastrectomy in this case. Multiple case reports and small case series have been published over the last decade describing the operative experience with transdiaphragmatic fistulas following bariatric surgery. The approaches described in these studies are diverse.(4-10) Clearly, a consensus as to the optimal approach for these cases has not been reached, nor is one likely forthcoming given their variety. The advantages of the left thoracoabdominal approach for transdiaphragmatic fistulas are, in our experience, numerous. It offers excellent exposure of the abdominal and thoracic
5
components of the lesion through a single incision. It provides a point of entry into the upper abdomen with a low burden of adhesions despite previous operations. Finally, it provides ready access to the high posterior thorax, to which peri-fistular abscesses or phlegma may extend. The positive outcome observed in the case described above is partly attributable to our uncomplicated entry into the abdomen and thorax, precise intraoperative characterization of the involved anatomy, and complete excision of abdominal and thoracic components of the fistula tract and associated phlegmon high in the chest. All of these elements, we believe, were facilitated by our preoperative selection of the left thoracoabdominal approach. Before selecting the thoracoabdominal approach for this case, we considered several alternatives described in the literature. We rejected an isolated midline laparatomy – described by Bruzzi, et al.(8) and Safadi, et al.(9) – for two reasons: first, the chest phlegmon was too complex and extensive for percutaneous drainage and demanded surgical exploration; second, access to the left upper quadrant through a midline laparotomy would have been complicated by adhesions from the patient’s multiple prior abdominal operations. We considered a combined left thoracotomy and midline laparotomy – similar to that utilized by Rebibo, et al.(10) – but this approach would also have been suboptimal. It would have required us to flip and re-prep the patient midway through the operation, prolonging the case, and we would have been unable to visualize the entire fistula tract through either incision, decreasing our chances of complete resection. The left thoracoabdominal approach can be associated with a high degree of morbidity, long postoperative hospitalization, and even death. Sasako and colleagues reported an increased incidence of post-operative complications (49% vs. 34%) and death prior to discharge (4% vs. 0%) in their study of the left thoracoabdominal versus transhiatal approach for gastroesophageal junction cancer.(11) In light of these associated risks, we suggest that the thorocoabdominal approach be reserved for cases in which exposure of complex anatomy would be insufficient with standard incisions and/or the burden of adhesive disease would prohibit uncomplicated entry via the anterior abdomen. Given the diversity and complexity of transdiaphragmatic fistulas following bariatric surgery, we assert that the left thoracoabdominal approach remains useful and should not be lost amid the growing pool of less invasive techniques. As such, we recommend that current and future generations of bariatric and GI surgeons familiarize themselves with the left thoracoabdominal approach and consider its application for the management of selected challenging cases.
6
DISCLOSURE STATEMENT The authors have no conflicts of interest.
REFERENCES 1. Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;21:1520–1529. 2. Silva LB, Moon RC, Teixeira AF, et al. Gastrobronchial fistula in sleeve gastrectomy and Roux-en-Y gastric bypass – a systematic review. Obes Surg. 2015;25:1959–1965. 3. Gonzalez R, Gallagher SF, Haines K, Murr MM. Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass. J Am Coll Surg. 2005;201(3):366– 374. 4. Fuks D, Dumont F, Berna P, et al. Case report – complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy. Obes Surg. 2009;19:261–264. 5. Garcia-Quintero P, Hernandez-Murcia C, Romero R, Derosimo J, Gonzalez A. Gastropleural fistula after bariatric surgery: a report of two cases. J Robotic Surg. 2015;9:163–166. 6. Dhillon A, Eltweri AM, Shah V, Bowrey DJ. Gastropericardial fistula after Roux-en-Y bypass for reflux disease. BMJ case reports. 2015;2015. 7. Nguyen D, Dip F, Hendricks L, Lo Menzo E, Szomstein S, Rosenthal R. The surgical management of complex fistulas after sleeve gastrectomy. Obes Surg. 2016;26:245–250. 8. Bruzzi M, Douard R, Voron T, Berger A, Zinzindohoue F, Chevallier JM. Open total gastrectomy with Roux-en-Y reconstruction for a chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis. 2016 Dec;12(10):1803–1808.
7
9. Safadi BY, Shamseddine G, Elias E, Alami RS. Definitive surgical management of staple line leak after sleeve gastrectomy. Surg Obes Relat Dis. 2015 Sep–Oct;11(5):1037–1043. 10. 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 May– Jun;10(3):460–467. 11. Sasako M, Sano T, Yamamoto S, et al. Left thoracoabdominal approach versus abdominaltranshiatal approach for gastric cancer of the cardia or subcardia: a randomized control trial. Lancet Oncol. 2006;7(8):644–651.
8
PII: DOI: Reference:
S1550-7289(17)30209-5 http://dx.doi.org/10.1016/j.soard.2017.04.022 SOARD3011
To appear in: Surgery for Obesity and Related Diseases Cite this article as: John S. Riley, Edmund K. Bartlett and Daniel T. Dempsey, A Left Thoracoabdominal Approach for Transdiaphragmatic Fistulas following Bariatric Surgery, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.04.022 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
TITLE: A Left Thoracoabdominal Approach for Transdiaphragmatic Fistulas following Bariatric Surgery
AUTHORS: John S. Riley, BA MSt1 Edmund K. Bartlett, MD2 Daniel T. Dempsey, MD1
AFFLIATIONS: [1] Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA [2] Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
SOURCES OF FUNDING: None.
CORRESPONDING AUTHOR: John S. Riley 3400 Spruce Street 4 Silverstein Pavilion Philadelphia, Pennsylvania 19104 [email protected] Telephone: (847) 302-5642 Fax: (215) 349-8195
SHORT TITLE: A Left Thoracoabdominal Approach For Fistulas
2
A Left Thoracoabdominal Approach for Transdiaphragmatic Fistulas following Bariatric Surgery
INTRODUCTION Transdiaphragmatic fistulas are a rare yet important long-term complication of bariatric surgery. While small fistulas can sometimes be managed endoscopically, large and complex fistulas usually require surgery.(1,2) The left thoracoabdominal approach, once used frequently in the treatment of surgical diseases of the distal esophagus, gastroesophageal junction, and upper stomach, has fallen out of favor in recent decades. In our experience, however, it remains useful for addressing complex transdiaphragmatic fistulas following bariatric surgery. The following case represents an instructive example.
CASE PRESENTATION AND MANAGEMENT Our patient is a 50 year old female with a history of multiple prior abdominal operations, most significantly a vertical banded gastroplasty (VBG) converted to sleeve gastrectomy (SG) five years prior to presentation. Thirteen months after the revision SG, she was involved in a motor vehicle accident that resulted in direct trauma to the left flank. Following this accident, she reported left-sided abdominal pain associated with nausea and constipation, and an abdominal CT demonstrated a large fluid collection adjacent to the gastric staple line, concerning for a leak. Conservative management with repeated percutaneous drainage was attempted but was ultimately unsuccessful, and she developed a chronic staple line leak complicated by a subphrenic abscess. Following a third attempt at percutaneous drainage 8 months prior to presentation, she developed left chest pain, shortness of breath, and a cough. A chest CT demonstrated a hydropneumothorax with suspected gastropleural fistula. Endoscopic stenting of the distal stomach and placement of a left thorocostomy tube failed to resolve her symptoms. On presentation to our center 6 months later, all percutaneous drains and the left chest tube had been removed. We ordered a CT with contrast and a contrast upper GI study (Figure 1), which demonstrated a persistent gastropleural fistula with associated phlegmon in the left chest. No VBG band was appreciated on the CT, as it had been removed at the time of SG conversion. A remnant of the stomach from the VBG to SG conversion or, less likely, a contained
3
extraluminal collection with peripheral pseudocapsule was noted at the superolateral aspect of the stomach, measuring 2.9 x 4.2 cm. Given the previous failures of conservative management, we elected definitive surgical management at this time. The patient’s BMI was 23.4, albumin 4.0 g/dL, and pre-albumin 22.9 mg/dL. Therefore we did not administer preoperative parenteral or enteral nutritional support.. A preoperative endoscopy was performed. The communication between the proximal stomach and the fundic segment was seen 42 cm from the incisors on the gastric side of the GE junction. The opening was approximately 1 cm in diameter, and purulent material was visualized beyond it.
Figure 1: (A) The preoperative chest CT. (B) The preoperative upper GI study; VBG vertical staple line (solid arrow), 1 cm opening (long dashed arrow) connecting the stomach lumen to the fundic segment, and origin of the gastropleural fistula (short dashed arrow). (C) The postoperative upper GI study with nasogastric tube in place; new TA staple line (solid arrow).
We began our operation with a left thoracoabdominal incision in the seventh interspace. The left costal margin was transected. The diaphragm was opened near the costal margin and the oblique muscles of the abdomen were opened in continuity with this. The diaphragm was then opened radially for a short distance. The peritoneum was entered, and we took down the splenic flexure of the colon. Above the spleen, tracking posteriorly, we identified a phlegmon that was in continuity with the apex of the fundus. We opened the fundus anteriorly, and we could see that it communicated with the main part of the stomach through a 1 cm opening around which we could see some staples. The apical fundus was mostly disconnected from the stomach by the previous VBG, but it was well-vascularized by two intact short gastric vessels. We opened the retropleural space posteriorly where the fistula tracked and decorticated the left lung. We dissected the fundus from the diaphragm and retroperitoneum, to which it was densely adherent. After freeing it up, it was only connected to the remaining stomach by the small opening described above. With a 38F Bougie in the esophagus and stomach, we then placed a TA 90 green stapler parallel to the long axis of the stomach to incorporate the previously-placed VBG vertical staple line and the opening into this somewhat isolated fundic segment. As the VBG band had been removed at the time of SG conversion, we were able to place the TA stapler just medial to the prior EEA stapled window without impediment. After performing an EGD, which demonstrated excellent patency of the cardia and an adequate lumen of the proximal stomach, we fired the TA stapler, excising the fundic segment (Figure 2). Air and methylene blue tests were negative. We then raised a well-vascularized omental pedicle flap, brought it up into the opening in the diaphragm, and used it to cover the staple line and fill the
4
subdiaphragmatic space. We placed a jejunostomy feeding tube, a Blake drain in the left upper quadrant, and two chest tubes in the left pleural space.
Figure 2: A diagram of the patient’s evolving anatomy. (A) VBG; gastric band (solid arrow) and vertical staple line (dashed arrow). (B) Converted to SG; EEA stapled window (solid arrow) and isolated fundic segment (dashed arrow). (C) Leak and fistula formation; 1 cm opening (solid arrow) from stomach lumen to fundic segment and origin of the gastropleural fistula (dashed arrow). (D) Excision of the fundic segment; new TA staple line (solid arrow).
Postoperatively the patient required 2 units of packed red cells. She was discharged on postoperative day 9 with her pain well-controlled on oral medications and tolerating bariatric clears with supplemental tube feedings. At her 1 month follow-up, she was tolerating a full liquid diet with occasional reflux but no nausea or vomiting. Her cough was markedly improved, and she reported resolution of her chronic chest pain and shortness of breath. At her 3 month followup, she was tolerating a regular diet without complaint.
DISCUSSION This case illustrates one of the recognized hazards of VBG to SG conversion, which requires care not to leave an isolated (or, as in this case, almost isolated) or devascularized segment of the fundus. Superior alternatives would have been excision of the fundus at the angle of His, which we later performed in our operation, or conversion to RYGB as described by Gonzales, et al.(3) It is unclear whether alternative revision would have prevented the staple line leak following trauma to the left flank, but the presence of the isolated fundic segment certainly complicated our dissection of the subsequent gastropleural fistula by its dense adherence to the diaphragm and retroperitoneum. It should also be noted, however, that the preservation of sufficient lumen of the proximal stomach by the index surgeon gave us the ability, at the time of our operation, to create a new staple line just medial to the vertical VBG staple line, thus obviating the need for total gastrectomy in this case. Multiple case reports and small case series have been published over the last decade describing the operative experience with transdiaphragmatic fistulas following bariatric surgery. The approaches described in these studies are diverse.(4-10) Clearly, a consensus as to the optimal approach for these cases has not been reached, nor is one likely forthcoming given their variety. The advantages of the left thoracoabdominal approach for transdiaphragmatic fistulas are, in our experience, numerous. It offers excellent exposure of the abdominal and thoracic
5
components of the lesion through a single incision. It provides a point of entry into the upper abdomen with a low burden of adhesions despite previous operations. Finally, it provides ready access to the high posterior thorax, to which peri-fistular abscesses or phlegma may extend. The positive outcome observed in the case described above is partly attributable to our uncomplicated entry into the abdomen and thorax, precise intraoperative characterization of the involved anatomy, and complete excision of abdominal and thoracic components of the fistula tract and associated phlegmon high in the chest. All of these elements, we believe, were facilitated by our preoperative selection of the left thoracoabdominal approach. Before selecting the thoracoabdominal approach for this case, we considered several alternatives described in the literature. We rejected an isolated midline laparatomy – described by Bruzzi, et al.(8) and Safadi, et al.(9) – for two reasons: first, the chest phlegmon was too complex and extensive for percutaneous drainage and demanded surgical exploration; second, access to the left upper quadrant through a midline laparotomy would have been complicated by adhesions from the patient’s multiple prior abdominal operations. We considered a combined left thoracotomy and midline laparotomy – similar to that utilized by Rebibo, et al.(10) – but this approach would also have been suboptimal. It would have required us to flip and re-prep the patient midway through the operation, prolonging the case, and we would have been unable to visualize the entire fistula tract through either incision, decreasing our chances of complete resection. The left thoracoabdominal approach can be associated with a high degree of morbidity, long postoperative hospitalization, and even death. Sasako and colleagues reported an increased incidence of post-operative complications (49% vs. 34%) and death prior to discharge (4% vs. 0%) in their study of the left thoracoabdominal versus transhiatal approach for gastroesophageal junction cancer.(11) In light of these associated risks, we suggest that the thorocoabdominal approach be reserved for cases in which exposure of complex anatomy would be insufficient with standard incisions and/or the burden of adhesive disease would prohibit uncomplicated entry via the anterior abdomen. Given the diversity and complexity of transdiaphragmatic fistulas following bariatric surgery, we assert that the left thoracoabdominal approach remains useful and should not be lost amid the growing pool of less invasive techniques. As such, we recommend that current and future generations of bariatric and GI surgeons familiarize themselves with the left thoracoabdominal approach and consider its application for the management of selected challenging cases.
6
DISCLOSURE STATEMENT The authors have no conflicts of interest.
REFERENCES 1. Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;21:1520–1529. 2. Silva LB, Moon RC, Teixeira AF, et al. Gastrobronchial fistula in sleeve gastrectomy and Roux-en-Y gastric bypass – a systematic review. Obes Surg. 2015;25:1959–1965. 3. Gonzalez R, Gallagher SF, Haines K, Murr MM. Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass. J Am Coll Surg. 2005;201(3):366– 374. 4. Fuks D, Dumont F, Berna P, et al. Case report – complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy. Obes Surg. 2009;19:261–264. 5. Garcia-Quintero P, Hernandez-Murcia C, Romero R, Derosimo J, Gonzalez A. Gastropleural fistula after bariatric surgery: a report of two cases. J Robotic Surg. 2015;9:163–166. 6. Dhillon A, Eltweri AM, Shah V, Bowrey DJ. Gastropericardial fistula after Roux-en-Y bypass for reflux disease. BMJ case reports. 2015;2015. 7. Nguyen D, Dip F, Hendricks L, Lo Menzo E, Szomstein S, Rosenthal R. The surgical management of complex fistulas after sleeve gastrectomy. Obes Surg. 2016;26:245–250. 8. Bruzzi M, Douard R, Voron T, Berger A, Zinzindohoue F, Chevallier JM. Open total gastrectomy with Roux-en-Y reconstruction for a chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis. 2016 Dec;12(10):1803–1808.
7
9. Safadi BY, Shamseddine G, Elias E, Alami RS. Definitive surgical management of staple line leak after sleeve gastrectomy. Surg Obes Relat Dis. 2015 Sep–Oct;11(5):1037–1043. 10. 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 May– Jun;10(3):460–467. 11. Sasako M, Sano T, Yamamoto S, et al. Left thoracoabdominal approach versus abdominaltranshiatal approach for gastric cancer of the cardia or subcardia: a randomized control trial. Lancet Oncol. 2006;7(8):644–651.
8