Management of gastrogastric fistula after laparoscopic Roux-en- Y gastric bypass

Abstract

Background Gastrogastric fistula (GGF) secondary to marginal ulceration (MU) is a reported complication of open Roux-en- Y gastric bypass; however, its frequency after laparoscopic gastric bypass (LGBP) is likely underreported. We present five cases of GGF and detail the management algorithm, including medical, endoscopic, and laparoscopic interventions. Methods Data from 282 patients undergoing LGBP from October 2002 to January 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with GGF were analyzed. Patients who developed GGF were compared with those who did not using Student’s t-test. Results Five patients (1.8%) subsequently developed GGF. Upper gastrointestinal radiographic evaluation documented the presence of a GGF in these patients, and upper endoscopy confirmed the diagnosis of MU. The mean interval between initial LGBP and subsequent diagnosis of GGF was 8.8 months. Patients who developed GGF were significantly younger (32.4 years vs 41.2 years; P = .007) and had lost significantly more weight 1 year after surgery (82.7% excess weight loss vs 70.0% excess weight loss; P = .003). No difference was noted when comparing operative time (164 minutes vs 148 minutes) or preoperative BMI (45.6 kg/m 2 vs 51.4 kg/m 2). All MU/GGF patients were treated initially with high-dose proton pump inhibitor (PPI) therapy. In one patient, the GGF closed with PPI therapy alone. A second patient’s GGF was successfully resolved with PPI therapy plus endoscopic injection of fibrin sealant. The remaining three cases were managed with laparoscopic division of the fistula after initial unsuccessful PPI therapy. In these patients, the GGF was of larger diameter than in those patients whose GGF closed with medical therapy alone. Conclusions MU/GGF should be considered in the differential diagnosis of all postoperative gastric bypass patients who present with abdominal pain. In our series, GGF was always associated with MU. Early diagnosis of GGF can be successfully treated with PPI therapy. Smaller-diameter tracts that do not resolve with medical therapy may respond to endoscopic therapy. Large-caliber fistula are less likely to respond to medical or endoscopic therapy but can be managed laparoscopically.