# Chronic gastro-diaphragmatic fistula following sleeve gastrectomy: a diagnostic and therapeutic dilemma

## TL;DR

A patient developed a rare chronic complication after weight-loss surgery, showing how difficult it can be to diagnose and treat such issues.

## Contribution

This case highlights the diagnostic challenges and management complexities of chronic gastro-diaphragmatic fistulas after sleeve gastrectomy.

## Key findings

- Chronic gastro-diaphragmatic fistula was diagnosed 11 months after sleeve gastrectomy.
- Imaging studies failed to detect the chronic, contained leak despite persistent symptoms.
- The patient required multiple interventions after post-operative deterioration from an uncontained gastric leak.

## Abstract

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure; however, gastric leaks remain a serious complication and are often diagnostically challenging. We describe a case of a chronic gastro-diaphragmatic fistula diagnosed 11 months following LSG. A 46-year-old female initially developed a contained gastric leak four weeks post LSG, managed with endoscopic primary closure. Despite reassuring imaging and endoscopic findings, she experienced persistent dysphagia, post-prandial vomiting, and referred left shoulder pain. Nearly one year after surgery, the presumed culprit of mediastinal migration of the proximal stomach was repaired laparoscopically; however, a small left crural collection was found without identifiable leak. Post-operatively, she deteriorated from an uncontained gastric leak, requiring multiple surgical interventions and prolonged critical care. This case highlights the limitations of imaging studies in detecting chronic, contained leaks and underscores the need for a high index of suspicion in patients with persistent, unexplained symptoms following LSG.