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

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.