Surgical Management of Gastro–Gastric Fistula After Divided Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Abstract

Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.

Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity

“…It is an uncommon but potentially important complication after divided LRYGB, with an incidence ranging between 1.5% and 6.0%. 38,39 The most common symptom of GGF is inadequate weight loss or weight gain. 40 However, intractable marginal ulceration, recurrent UGI hemorrhage, pain and stricture formation can all herald the presence of a GGF.…”

“…40 However, intractable marginal ulceration, recurrent UGI hemorrhage, pain and stricture formation can all herald the presence of a GGF. 39 The causes of GGF are varied, with iatrogenic, incomplete gastric transection likely to be the most common cause. 41 In addition, subclinical ASL from the gastrojejunal anastomosis or perforation of a marginal ulceration could possibly result in the formation of a GGF.…”

“…41 In addition, subclinical ASL from the gastrojejunal anastomosis or perforation of a marginal ulceration could possibly result in the formation of a GGF. 39 Given the relative rarity of this complication and the myriad of possible presenting symptoms, any patients with persistent nausea, vomiting, insufficient weight loss, weight gain, intractable marginal ulceration, persistent epigastric pain, recurrent UGI hemorrhage and gastrojejunostomy anastomotic stricture should undergo UGI endoscopy and contrast UGI series to elucidate the problem. If the investigations reveal a GGF, these patients should be treated with proton pump inhibitors and sucralfate.…”

“…This course of medical management has been shown to result in symptom resolution in 37% of patients who experience this complication. 39 Symptomatic GGF will require surgical management using either a laparoscopic or open approach. Most experienced laparoscopic surgeons would opt for the minimally invasive approach, combining laparoscopy with intraoperative endoscopy to identify, isolate and transect the fistulous tract with an Endo GIA stapler.…”

Anatomy-based surgical strategy of gastrointestinal fistula treatment

“…The pouch size determines the need for the fistula excision or exclusion. If the pouch is big, the tract should be excised by vertical transection of the gastric remnant just medial to the fistula [25,26]. Other options include the transection of GGFs with an Endo GIA stapler, reinforcement of the staple line, and intraoperative confirmation of fistula closure by endoscopy if possible, or methylene blue.…”