Triple Modality Endoluminal Management for Complex Gastrogastric Fistula after Laparoscopic Roux-en-Y Gastric Bypass

James Villamere, MD, Gautam Sharma, MD, John Rodriguez, MD, Kroh Matthew, MD. Cleveland Clinic Foundation

Gastrogastric fistula is a rare but significant complication after laparoscopic roux-en-Y gastric bypass. It can lead to weight recidivism and marginal ulcer and typically requires revisional surgery.

We present a 34 year-old female with a body mass index of 45.7 kg/m2 who presented with radiologic and endoscopically confirmed gastrogastric fistula and stricture of the gastrojejunal anastomosis eight-weeks after a laparoscopic roux-en-Y gastric bypass for morbid obesity performed at an outside center. The patient’s initial gastric bypass was complicated by an early gastrojejunal anastomotic leak and sepsis managed with surgical drainage, endoluminal stent, and gastric remnant feeding tube.

This complex gastrogastric fistula, with stricture of the gastrojejunostomy, was managed with multimodal endoscopic techniques, which are described in a step-wise manner. A mucosectomy of the gastrogastric fistula is performed, followed by OverStitch endoscopic suture closure of the fistula. An Ovesco endoscopic clip is placed over the closure site for reinforcement and balloon dilatation of the strictured gastrojejunostomy is accomplished. Post-operative upper GI-series demonstrated closure of the gastrogastric fistula with a patent gastrojejunal anastomosis. The patient recovered well post-operatively and had excellent results on short-term follow-up.

Endoscopic closure of gastrogastric fistula is safe and feasible. Early follow-up results are promising. The long-term durability for permanent fistula closure is a topic for debate.

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