The prevalence of laparoscopic techniques favors the development of bariatric surgery. Minimally invasive techniques are associated with fewer complications and lower mortality in the perioperative period and laparoscopic access is currently preferred in bariatric surgery (1-3). Among the many methods of surgical treatment of obesity, sleeve gastrectomy is becoming increasingly popular. Over the last decade, sleeve gastrectomy has become one of the most frequently performed bariatric procedures and the effectiveness and safety of this method has been confirmed in numerous reports (4-8). The most feared complications associated with sleeve gastrectomy include leakage within the staple line. There are different theories on the causes of the leakage within the staple line after sleeve gastrectomy. A number of different methods of treatment were described in the case of this complication. In this paper, we will present a case of a patient in whom there was a leakage resulting from cutting the bougie used to calibrate the sleeve, and fibrin sealant, applied endoscopically, was used in the treatment.

A 46-year-old patient with BMI of 44.6 kg/m², without comorbidities, was qualified for sleeve gastrectomy. During the surgery, after sleeve gastrectomy and suturing the staple line with a continuous suture, abnormal cluster of staples was found at the top of the produced sleeve. After removal of the resected part of the stomach from the peritoneal cavity, the end of the bougie used for calibration with a length of about 10 cm was found in the gastric lumen. The bougie was cut in spite of constant monitoring its position before each subsequent use of the endostapler. The gastric tube was cut off during the use of the penultimate cartridge at the upper part of the stomach, close to the angle of His. No leakage was found after checking the staple line. Due to the existing doubts, intraoperative gastroscopy was performed. In endoscopy, no remnants of the tube were found, macroscopically, the staple line was correct. Air insufflation of the stomach was performed through an endoscope after immersion from the peritoneal cavity in saline solution and no leakage was found. An unsuccessful attempt was made to suture with another continuous suture, due to the difficulty of maintaining pneumoperitoneum and the surgery was finished at this stage. The patient, on the first postoperative day, was in good general condition, the body temperature was 37°C and the pulse was 78/minute. During a physical examination, the abdomen was slightly painful in the left side of the upper abdomen, without peritoneal signs. The drain from the peritoneal cavity took 140 milliliters of sero-bloody fluid. A water-soluble contrast study was performed and a leakage of contrast was found in the upper part of the stomach (fig. 1). The patient was qualified for a revision surgery. Re-laparotomy was decided on, not re-laparoscopy because of the difficulty to obtain pneumoperitoneum during the first surgery. Intraoperatively, the leak was identified and sutured with interrupted sutures, the peritoneal cavity was rinsed, and drains were introduced into the peritoneal cavity and the abdominal integuments. The patient, after revision surgery was fed parenterally, intravenous antibiotics was administered. On the 5th day after the revision surgery, a contrast swallow test was performed and no leakage characteristics were found. On the 7th day after the revision surgery, oral diet was administered. On the 11th postoperative day, in generally good condition, the patient was discharged home. The patient was re-admitted to the hospital 71 days after the first surgery because of clinical and radiological signs of late fistula, without leakage of contrast into the abdominal cavity (fig. 2). A water-soluble contrast study revealed a narrow band of contrast outside the gastric lumen in the upper part of the stomach, at the greater curvature. CT scan revealed small gas bubbles in the area of the spleen and the greater curvature of the stomach and in the vicinity of the front surface of the pancreas – outside the gastrointestinal tract lumen. The image suggested the suture line dehiscence with limited passage of gastric contents outside the gastric lumen, to the left of the infradiaphragmatic area and between the stomach and the pancreas. No free air or collections of fluid in the peritoneal cavity were found. Conservative therapy, broad spectrum antibiotics, total parenteral nutrition were administered. The patient did not consent to a self-expandable stent after being informed about the possibility of stent migration. Two trials to deploy enteral nutrition also failed because every time the intestinal tube was blocked. Due to the persistence of chronic gastric fistula, despite properly conducted conservative treatment, the patient went through 3 endoscopic sessions of closing the fistula with fibrin sealant Tissel-Lyo 2 ml (Baxter). The glue was applied endoscopically using the Duplocath (Baxter) set with a length of 180 centimeters. It is a dual-channel catheter adapted for the use with flexible endoscopes provided with a syringe and an applicator for administration of fibrin sealant components. The patient sessions using tissue glue took place, respectively, on the 171st, 185th and 199th day after the sleeve gastrectomy. During subsequent endoscopy and radiological examinations, decrease in the fistula was observed. No contrast outflow outside the gastrointestinal tract lumen was observed during a recent radiological examination (fig. 3). Drinking was recommended and oral diet in subsequent days. The patient, in generally good condition, was discharged home after 148 days of the second hospitalization. To date, she remains under the control of a outpatient department, with no radiological and clinical evidence of fistula, with very good results in terms of weight loss.