Step-by-step Laparoscopic Revision of Roux-en-Y Gastric Bypass for Gastrogastric Fistula, Partial Gastrectomy, and Roux-en-Y Gastrojejunostomy

Sofiane El Djouzi, MD, MS, FRCS, FACS, Sean McCalmon. Poplar Bluff Regional Medical Center

Background: A video presentation of J.W a 41-year-old Caucasian woman former morbidly obese who underwent laparoscopic Roux-en-Y gastric bypass in 2004. She lost a significant amount of body weight since but has regained some back the last few years. She presented with a nearly 10-year history of left upper quadrant abdominal pain, nausea and bilious vomiting. She had also experienced a nearly disabling dysphagia. Her diagnostic work-up unveiled a sizeable gastro-gastric fistula (GGF). The patient consented for corrective surgery.

Method: After Veress needle established pneumoperitoneum a one 12 mm and three 5 mm trocars were used for the laparoscopic exploration. The anatomy was accurately identified after lysis of adhesions. Using liver retractor, the left lobe was carefully pushed superiorly allowing for an even better exposure. The GGF was dissected and excised en bloc with a segment of the Roux limb and a partial gastrectomy. The Roux-en-Y anatomy was at this point reconstructed using a hybrid approach with linear GI stapler and suturing. Upper endoscopy was obtained intra-operatively confirming the patency of the newly constructed gastrojejunostomy.

Results: The operative time was 110 min with EBL < 10 cc.  No complications were encountered. UGI on POD # 1 showed adequate anatomy with no leak or obstruction. The patient tolerated diet well and was discharged home after 48 hours of hospital stay with minimal incisional discomfort. A 9 month-follow has shown no recurrence of the patient’s prior complaints and an improved weight loss (latest BMI: 24.7).

Conclusion: laparoscopic revision of Roux-en-Y gastric bypass for symptomatic gastro-gastric fistula is safe and efficacious. It leads to a two folds benefit: an overall improvement of the patient quality of life and better weight loss. 

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