Presentation and Management of Gastrogastric Fistula After Roux-en-Y Gastric Bypass

Saber Ghiassi, MD MPH, Ruby Gatschet, MD, Daniel Moon, MD, Keith Boone, MD FACS, Kelvin Higa, MD FACS. University of California, San Francisco, Fresno

 

INTRODUCTION:
Gastrogastric fistula (GGF), a communication between the gastric pouch and gastric remnant, is a rare but important complication of Roux-en-Y gastric bypass (RYGB) that can lead to weight recidivism and marginal ulcer. We describe our experience with the presentation and management of this complication.

METHODS:
We performed a retrospective chart review of patients who had undergone treatment of GGF from 2007 to 2011. Presentation, diagnostic and therapeutic modalities, and complications were noted. Weight loss before and after treatment of GGF was compared using the Student’s paired t-test.

RESULTS:
Eighteen patients with GGF were identified. They had undergone 6 open RYGB and 12 laparoscopic RYGB. Five were complicated by leak. Eight were referred from outside institutions. Average interval between RYGB and presentation was 6±1 years. Most common presentation was abdominal pain (67%), followed by weight recidivism (56%) and ulcer (44%). Sixteen endoscopies and 7 out of 10 upper GI studies were diagnostic. One patient was successfully treated with endoscopic self-expanding stent. Three patients failed endoscopic management with Endoclips. Seventeen patients underwent remnant gastrectomy, 9 patients also underwent pouch gastroplasty, and an additional 8 patients underwent revision of gastrojejunostomy. Postoperative complication rate was 17%. One postoperative leak was treated with image-guided drainage and another with endoscopic self-expanding stent. One patient underwent endoscopic balloon dilatation of gastrojejunostomy. Mean follow-up was 10±3 months. Mean percent excess weight loss was 46%±8 at the time of surgery for GGF vs. 64%±5 at follow-up (p=0.005).

CONCLUSION:
Gastrogastric fistula is a rare complication of RYGB that can lead to weight regain and marginal ulcer. Etiologies include anastomotic leak, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of foreign body. Endoscopy is diagnostic but its therapeutic efficacy is very low. Surgery, including remnant gastrectomy, is the definitive treatment with acceptable complication rate. Treatment of GGF results in resolution of symptoms and improved weight loss.


Session Number: Poster – Poster Presentations
Program Number: P445
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