Matthew Tufts, Thadeus Trus, MD, Stuart R Gordon, MD. Dartmouth-Hitchock Medical Center
Background: Gastrogasrtic fistula (GGF) is a rare but serious complication of gastric bypass surgery. Overall incidence has been reported to be from 1.2% to as high as 12 %. Pathogenesis is due to incomplete division of the stomach, staple line breakdown, or a leak/marginal ulcer leading to subsequent fistula formation. Symptoms included epigastric pain, reflux, lack of early satiety and weight gain Traditionally, fistula closure is achieved by open or laparoscopic revisional surgery. Recently, endoscopic closure has been reported with variable levels of success.
Methods: All Apollo Overstitch™ GGF closures at our institution were followed prospectively. Inclusion criteria were, history of gastric bypass surgery and endoscopic documentation of GGF. All patients underwent mucosal cauterization using argon plasma coagulation of the fistula tract prior to closure. In some cases closure was augmented by large over the scope clip placement. We examined, time from index operation to fistula diagnosis, fistula size, technique of bypass (open versus laparoscopic), symptoms of GGF, mechanism of fistula formation, number of endoscopic interventions, length of follow up and degree of fistula closure.
Results: 6 patients underwent endoscopic GGF closure. 5 patients had open gastric bypass, 1 had laparoscopic bypass. GGF diagnosis was made 13.3 years after index operation (range 8-20 years). GGF fistula was secondary to staple line breakdown in 4 patients, 2 were due to marginal ulceration/perforation. Average fistula size was 2cm, (range .5-8cm). The most common symptoms of fistula were weight gain and reflux Average follow up was 20.8 months, (range 1-51 months) An average of 2 endoscopic closure attempts were performed( range 2-5). 2 patients also underwent over the scope clip placement. 2 patients experienced weight loss after endoscopic closure. 4 patients have endoscopic documentation of persistent fistula, one was lost to follow up and 1 has yet to be endoscopically re-evaluated. 1 patient underwent operative revision after closure failure.
Discussion: GGF is a rare complication of gastric bypass. GGF should be suspected in bypass patients that have reflux or weight gain after bypass surgery. . These data suggest GGF fistula endoscopic closure has a high failure rate, particularly after staple line breakdown. Operative revision remains the optimal treatment. More studies are needed to elucidate which patients may respond to endoscopic fistula closer.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95624
Program Number: P145
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster