Is the gastric fistula after sleeve gastrectomy inescapable ?

Objectives. The risk of gastric fistula is evaluated about 3 % after sleeve gastrectomy and may compromise the expansion of this bariatric operation.Methods. Retrospective monocentric study from April 2003 to January 2012 : 1 597 patients (1 480 sleeve gastrectomies and 117 duodenal switches) including 92,5 % women with BMI 35 to 61, aged 18 to 71 years. Global mortality 0,2 %. Sleeve mortality 0,6 ‰. Morbidity 7,5 %. 95 gastric fistulas (5,9 %) : 9 fistulas without abscess medically treated, 51 early fistulas surgically treated and secondary endoscopically since 2008 (53,5 %), 35 late fistulas endoscopically treated.Results. One death (1 %). 82 recoveries (87 %) with 68,5 % in three in six months, three still evolutive fistulas at one year (3 %) and nine chronic fistulas after one year reoperated.Comments. Sleeve gastrectomy becomes the standard in bariatric surgery with her simplicity, her efficiency, her tolerance and her comfort. The cardia is a delicate area sensitive to hyperpression and technical faults. The quality of the suture depends on the clarity of the dissection and on the use of a continuous suture with slow resorption monofil. The control of alimentation limits the effects of mediogastric hyperpression and postoperative pyloric dysfunction. These measures have allowed to reduce the risk of gastric fistula to 3 % in 2011.Conclusion. The gastric fistula is not inescapable. Her prevention is difficult and needs better knowledge of the cardia and better understanding of the functional consequences of sleeve gastrectomy allowing to choice the best surgical technics and postoperative alimentary procedures.