Background

The Nissen-sleeve is an alternative procedure to the roux en Y gastric bypass to treat patients with obesity and GERD. This procedure has shown to have promising weight loss results with a relatively low complication rate. Early postoperative proximal leaks have been reported, with overall good outcomes with early surgical intervention. This is a case of a 51-year-old female with obesity and Nissen fundoplication who underwent a sleeve gastrectomy at an outside hospital. Her outside course was complicated by necrosis of the fundoplication, subsequent resection, and proximal sleeve leak. She underwent multiple stents and endoscopic suture repairs but continued to have worsening sepsis and an uncontained leak. She was taken for laparoscopic total gastrectomy with a postoperative course complicated by esophageal stump dehiscence managed with endoscopic esophageal drain placement. The patient has been recovering at home on parental nutrition and is planned for esophagojejunostomy reconstruction in December 2022. There is no clear etiology of this complication, however, it is possible that the sleeve created torque on the wrap leading to an ischemic complication. This case illustrates that while Nissen-sleeve procedures are feasible, the roux en Y gastric bypass remains the gold standard for patients with obesity and GERD. Additionally, the safest approach in complex cases such as this would be to take down the fundoplication at the initial sleeve operation and to transfer complex cases to a tertiary center for management of complications.