Minimally Invasive Management of Gastro-gastric Fistula With Eroding Mesh Following Roux-en-Y Gastric Bypass

Jeremy M Linson, MD, Abubaker Ali, MD, Michael Latzko, MD, Ziad Awad, MD, FACS, Bestoun Ahmed, MD, FRCS, FACS. University of Florida College of Medicine Jacksonville

Background: We present a case of minimally invasive management of gastro-gastric fistula and erosion of mesh following open Roux-en-Y gastric bypass. The patient is a 50 year old African-American female with a history of morbid obesity (BMI 47.9), hypertension and degenerative joint disease. Thirteen years prior to presentation she underwent open Roux-en-Y gastric bypass with retro-colic and retro-gastric gastrojejunostomy. A polypropylene mesh was used to reinforce the gastrojejunostomy staple line.  She experienced successful weight loss, but she began to regain weight about 10 years after her initial operation. Then several months prior to her presentation she developed progressive abdominal pain and PO intolerance and then developed intermittent hematemesis exacerbated by eating. Upper GI fluoroscopy and EGD revealed a gastro-gastric fistula with erosion of the mesh into the lumen.

Method: We planned for laparoscopic and endoscopic take-down of the gastro-gastric fistula. Upon entering the abdomen laparoscopically, we proceeded with lysis of dense adhesions between the posterior wall of the liver and the gastric pouch, gastric remnant and roux limb. Once these structures were mobilized, no mesh was visible on the exterior of the bowel. We then passed the endoscope with some difficulty beyond the mesh and into the gastric remnant. The EGD scope was used to guide cross-stapling of the gastric remnant just distal to the fistula. The fistula was then taken down with the laparoscopic linear stapler.  Due to partial obstruction of the gastrojejunotomy resulting from the intra-luminal position of the eroded mesh, the decision was made to remove the mesh. Due to the small size of the anastamosis and difficult mesh position, we were not able to safely extract the mesh endoscopically, so an enterotomy was created just distal to the anastamosis, and the mesh was extracted from the roux limb laparoscopically. The enterotomy was then closed with the laparoscopic stapler.

Results: Post-operative upper-GI fluoroscopy showed good transit of contrast through the roux limb without evidence of leak or fistula. The patient was started on PO diet on POD1 and discharged on POD2.

Conclusions: Gastro-gastric fistula with mesh erosion following Roux-en-Y gastric bypass can be managed safely with a minimally invasive approach.

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