Surgical Management Algorithm for Intrathoracic Sleeve Migration: A Retrospective Series and Literature Review.

Background: With the increase in utilization of laparoscopic sleeve gastrectomy (LSG), intrathoracic sleeve migration (ITSM) has introduced a novel challenge for bariatric surgeons. Despite being an underreported complication, effective and safe solutions for ITSM are being sought. The aim of this study is to present our center's experience as well as a comprehensive review of the literature on ITSM. Accordingly, we propose an algorithm for the surgical management of ITSM. Methods: We conducted a retrospective chart review of 4000 patients who underwent LSG at our center. ITSM was clinically suspected with gastroesophageal reflux disease (GERD) symptoms and/or epigastric pain resistant to proton pump inhibitors. Diagnosis of ITSM was confirmed in all patients by three-dimensional computed tomography (3D-CT) volumetry. Several corrective procedures were offered based on the findings of the 3D-CT volumetry, esophagogastroduodenoscopy, and the diaphragmatic pillars' condition: cruroplasty with gastropexy, one anastomosis gastric bypass (OAGB), or Roux-en-Y gastric bypass (RYGB) with or without re-sleeve gastrectomy, omentopexy, or ligamentum teres augmentation. We conducted a literature review of ITSM using several databases. Results: Fifteen patients were diagnosed with postoperative ITSM. The most common presenting complaint was severely worsened GERD symptoms not responding to medical treatment. The mean time interval between the primary operation and diagnosis of ITSM was 38.8 ± 29.1 months. Three patients had re-sleeve gastrectomy and gastropexy, 5 patients had OAGB, and 7 patients had RYGB. The mean postoperative body mass index was 31.2 ± 4.9 kg/m 2 . No case of recurrent ITSM was detected during follow-up. Our electronic database search yielded 19 studies to be included in our review, which included 201 patients. Conclusion: A high index of suspicion is required to diagnose ITSM. CT volumetry with 3D reconstruction may be the most sensitive diagnostic modality. ITSM management should depend on the results of the diagnostic workup and the condition of the diaphragmatic pillars during surgery.