MULTIMEDIA ARTICLE Fistulojejunostomy for Chronic Fistula After Sleeve Gastrectomy Tigran Poghosyan 1 & Guillaume Levenson 1 & Matthieu Bruzzi 1 & Claire Rives-Lange 2 & Sebastien Czernichow 2 & Jean-Marc Chevallier 1 & Richard Douard 1 # Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract The most dreadful complication after sleeve gastrectomy (SG) is staple line leak. Its rate varies between 1 and 2%. With the development of interventional endoscopy, its treatment is currently fairly standardized and allows healing in the majority of cases without revisional surgery. However, if endoscopic treatment fails, surgical treatment becomes unavoidable. Fistulojejunostomy is a surgical option in the management of chronic fistula after SG. Laparoscopic fistulojejunostomy in a patient with chronic fistula after SG is difficult but feasible. This procedure allows complete healing and nutritional recovery in the case of failure of other endoscopic modalities. Keywords Sleeve gastrectomy . Leak . Chronic fistula . Fistulojejunostomy . Bariatric surgery Introduction Due to good efficiency and low morbidity, sleeve gastrectomy (SG) is currently one of the most performed procedures in bar- iatric surgery. The most dreadful complication after SG is staple line leak. Its rate varies between 1 and 2%. With the development of interventional endoscopy, its treatment is currently fairly stan- dardized and allows healing in the majority of cases without revisional surgery. However, if endoscopic treatment fails, surgi- cal treatment becomes unavoidable. Fistulojejunostomy is a sur- gical option in the management of chronic fistula after SG [1–4]. Case Presentation This is a case of 27-year-old patient with history of SG com- plicated by acute leakage at the upper third of the stomach and requiring emergency laparoscopic revision for lavage and ex- ternal drainage. At day 10, external drain was removed, and internal drainage by double pigtail was performed. In parallel, mid-gastric stricture was treated by endoscopic dilation and stenting. Chronic fistula with persistence of perigastric collec- tion after 6 months of endoscopic treatment was noted. After discussion at the multidisciplinary meeting, we decided to perform a laparoscopic fistulojejunostomy (Video). The patient underwent fistulojejunostomy in French posi- tion. Port site positions were similar to port sites used for conventional laparoscopic Roux-en-Y gastric bypass proce- dure performed in our department. Operating time was 240 min. Schematically, this procedure could be divided into 3 steps. The first step is a complete adhesiolysis of the sleeved stomach allowing identification of fistula. This step is difficult and involves risks of adjacent structures injury due to dense fibrosis. Adhesiolysis should be started from the antrum, grad- ually releasing the stapling line, the anterior side, and then the posterior side of the stomach. The dissection from bottom to top allows to find the inferior edge of the fistula. Dissection is completed by release of esophagogastric junction, identifica- tion of the left crus, and mobilization of fistula edge. The second step is a fistulojejunostomy creation at 50 cm from ligament of Treitz. A strip is used to suspend the mounted loop. The 2 cm jejunotomy is performed on the anti-mesenteric edge following by a manual anastomosis using the self-locking absorbable suture. The jejunum is di- vided on the left side of the anastomosis, thus separating the alimentary and the biliopancreatic limbs. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-020-04660-8) contains supplementary material, which is available to authorized users. * Tigran Poghosyan tigran.poghosyan@aphp.fr 1 Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, 20 Rue Leblanc, 75015 Paris, France 2 Department of Nutrition, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, Paris, France Obesity Surgery https://doi.org/10.1007/s11695-020-04660-8