Case Report
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World J Gastrointest Surg. Dec 27, 2013; 5(12): 337-340
Published online Dec 27, 2013. doi: 10.4240/wjgs.v5.i12.337
Fatal aortoesophageal fistula bleeding after stenting for a leak post sleeve gastrectomy
Majid A Almadi, Fahad Bamihriz, Abdulrahman M Aljebreen
Majid A Almadi, Abdulrahman M Aljebreen, Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh 11461, Saudi Arabia
Majid A Almadi, Gastroenterology Division, the McGill University Health Center, Montreal General Hospital, McGill University, Montreal H3G 1A4, Canada
Fahad Bamihriz, Surgery Division, King Khalid University Hospital, King Saud University, Riyadh 11461, Saudi Arabia
Author contributions: Almadi MA contributed towards writing and drafting the article, revising it critically for important intellectual content and giving final approval of the version to be published; Bamihriz F and Aljebreen AM both contributed towards revising the article critically for important intellectual content and giving final approval of the version to be published.
Supported by The Deanship of Scientific Research at King Saud University funding of this research through the Research Group Project, No. RGP-VPP-279
Correspondence to: Dr. Majid Abdulrahman Almadi, MBBS, FRCPC, MSc, Clinical Epidemiology, Assistant Professor of Medicine, Gastroenterology Divisions, King Khalid University Hospital, King Saud University, PO Box 2925(59), Riyadh 11461, Saudi Arabia.
Telephone: +966-1-4679167 Fax: +966-1-4671217
Received: August 24, 2013
Revised: October 22, 2013
Accepted: November 15, 2013
Published online: December 27, 2013

Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents (SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwent a computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.

Keywords: Stents, Esophagus, Leak, Surgery, Complication, Aortoesophageal fistula, Endoscopy, Bariatric surgery, Sleeve gastrectomy

Core tip: One modality for managing staple line leaks after laparoscopic sleeve gastrectomies depends on a non-surgical approach, including elimination of oral intake, parenteral nutrition, use of broad spectrum antimicrobial therapy, drainage procedures and the use of esophageal self-expandable metal stents for sealing these leaks and the induction of tissue hyperplasia that would close these defects. Although this seems as a less invasive procedure when compared to a repeated surgical procedure and there is a body of evidence in the literature that supports such an approach, it is not void of complications. Here we report a fatal aortoesophageal fistula as a complication.