ORIGINAL CONTRIBUTIONS Intra-thoracic Sleeve Migration (ITSM): an Underreported Phenomenon After Laparoscopic Sleeve Gastrectomy Alan A. Saber 1 & Saeed Shoar 1 & Mousa Khoursheed 2 # Springer Science+Business Media New York 2017 Abstract Background Despite its technical simplicity, laparoscopic sleeve gastrectomy (LSG) complications are increasingly re- ported. Intra-thoracic sleeve migration (ITSM ) is a rare com- plication after LSG which has been inconsistently addressed in the literature. Aims The purpose of this study was to emphasize ITSM oc- currence after LSG and evaluate the perioperative factors as- sociated with its development. Methods Between January and July 2016, LSG patients diag- nosed with ITSM at two bariatric surgery departments were identified. Perioperative factors were assessed for all the pa- tients and compared between two groups, LSG alone and LSG with concomitant hiatal hernia (HH) repair (HHR). Results A total of 19 patients (6 males and 13 females) were included. Central obesity was present in 18 patients (94.7%). Nine patients (47.4%) had concomitant hiatal hernia repair during their original LSG. Post-LSG GERD (94.7%) (38.9% de novo and 61.1% recurrent) and post-LSG constipation (57.9%) were commonly associated with ITSM. Severe re- fractory GERD was the most common presentation for ITSM (94.7%), followed by epigastric pain (47.4%), persis- tent nausea/vomiting (36.8%), and dysphagia (21.1%). Time interval between primary LSG and ITSM diagnosis ranged from 1 day to 3 years. Patients with LSG and concomitant HHR presented with higher post-LSG BMI compared to the LSG patients (37 ± 6.4 kg/m 2 vs. 30.1 ± 6.3 kg/m 2 , p = 0.03). All the patients underwent successful reduction of ITSM and subsequent HHR. Conclusion Central obesity, chronic constipation, post-LSG GERD, and concomitant HHR are commonly seen in post- laparoscopic sleeve gastrectomy intra-thoracic sleeve migration. Keywords Laparoscopic sleeve gastrectomy . Hiatal hernia . Intra-thoracic sleeve migration Introduction Laparoscopic sleeve gastrectomy (LSG) has gained a wide acceptance as a stand-alone procedure for morbid obesity [1, 2]. Its popularity is, in large, due to its technical simplicity and lower morbidity and mortality rate compared to the commonly performed Roux-en-Y gastric bypass [3]. Nevertheless, post- operative complications after LSG are increasingly reported in the literature [4–7]. Hiatal hernia (HH) is commonly identified in patients un- dergoing LSG [8]. Current guidelines urge concomitant HH repair (HHR) and LSG when the defect is found intra- operatively [9, 10]. However, there is controversy on the best approach to the LSG patients who are diagnosed with HH postoperatively [11]. Intra-thoracic sleeve migration (ITSM ) is a sliding HH which occurs after LSG [12]. The complication has been in- consistently reported in the literature [4, 5, 12, 13]. Our study aimed to investigate the perioperative factors associated with post-LSG ITSM development. * Alan A. Saber saber6231@gmail.com 1 Metabolic and bariatric surgery institute, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY, USA 2 Department of Bariatric Surgery, Kuwait Health Sciences Center, Al Jahra, Kuwait OBES SURG DOI 10.1007/s11695-017-2589-6