Endoscopic, Conservative, and Surgical Treatment of the Gastrogastric Fistula: The Efficacy of a Stepwise Approach and Its Long-Term Results

Abstract

Background: Treatment of gastrogastric fistula (GGF) has not been consensual. The aim of this study is to evaluate the efficacy of a stepwise approach of GGF in the long term. Methods: This is a retrospective case-series study. Thirty-one patients underwent open (71%) or laparoscopic (29%) Roux-en-Y gastric bypass (RYGB), where 20 (64.5%) had a banded pouch. Those 31 cases were referred to the authors' clinic for GGF treatment. The mean time between the primary surgery and GGF diagnosis by endoscopy or radiography was 31 months. Outcomes were evaluated after conservative, endoscopic, and surgical treatment. Mean follow-up was 39.7 months (10–97 months). Results: Patients were referred presenting weight regain (100%), epigastric pain (51.6%), and upper digestive hemorrhage (9.6%) due to marginal ulcer (35.5%). GGF was located at the angle of His (51.6%) and two other sites (gastric body and close to the gastrojejunal anastomosis). Etiology was defined in 27 (87%) due to previous acute gastric leak (54.8%) and band erosion (32.3%). Treatment for GGF was conservative (n=11; healing=2, 18.2%) and endoscopic (n=6; healing=4, 66.7%). In the surgical group (n=14), fistula transection by laparoscopy (n=6) and by laparotomy (n=8) were carried out. In this last group, a remnant gastrectomy was done (n=5). Fistula closure was achieved in 13 (92.9%) patients in the surgical group, which had two cases of acute fistula treated by endoscopy. Overall outcomes were symptom control and weight loss. Conclusions: GGF has been effectively treated by revisional surgery. Endoscopic management in selected situation has a relatively high success rate.