Minimally Invasive Repair of Gastro-gastric Fistula After Roux-en-Y Gastric Bypass

Pablo Quadri, MD, Raquel Gonzalez-Heredia, MD, PhD, Kristen Patton, MD, Lisa Sanchez-Johnsen, PhD, Enrique F Elli, MD, FACS. UIC

Introduction: Since the introduction of divided Roux -en- Y Gastric Bypass (RYGBP), the incidence of gastro-gastric fistula has been greatly reduced. When a fistula is present, it is usually followed by weight gain, abdominal pain or refractory ulcers. Fistulization between gastric segments is a late complication after (RYGBP).  There are many ways to approach the resolution of this complication which depends on the characteristics of the fistula.  

Material and Methods: The patient was a 46-year-old woman with history of mild GERD, hypertension, depression and fibromyalgia. She reported having the Gastric Bypass surgery in 2003.  It went well, but two years ago, she started to have severe epigastric pain, GERD and bloating.  The EGD showed a 3 cm gastro-gastric fistula, in communication with the gastric remnant and a patent gastro-jejunostomy. The patient then underwent minimally invasive robotic-assisted repair of the fistula.

Results: The procedure started with a diagnostic laparoscopy that showed adhesions. The liver was densely adhered to the small bowel and the stomach. On the lateral side, the remaining stomach was densely adhered to the spleen and the liver. Using the monopolar hook, those adhesions were removed.  With a clear dissection and anatomy, we performed an intra-operative endoscopy to confirm the anatomy. Using the monopolar hook, the esophagus was dissected cephalically in the mediastinum.  There was a medium hiatal hernia. It was repaired using interrupted non absorbable 2.0 suture to close the anterior hiatus. The gastric pouch was completely dissected from the gastric remnant.  With the fistula completely dissected we used a stapler for the transection.  In this way, the gastro-gastric fistula was completely dismantled.  Another endoscopy was performed to visualize the closure and no air leak or bleeding was seen. There were no intra- or post-operative complications. The estimated blood loss was 80cc.  The patient’s symptoms improved dramatically after surgery, being discharged on POD 1.

Conclusions: Some patients with gastro-gastric fistula will be completely asymptomatic, and can be managed conservatively. There is no standardized surgical treatment approach for symptomatic gastro-gastric fistula. The use of a robotic-assisted approach and intra-operative endoscopy are tools that can facilitate dissection and precision, and provide surgeons with a better visualization of the anatomy while reducing morbidity and mortality rates.

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