Successful Endoscopic Closure of a Gastro-Gastric Fistula with Endo-Clips

Abstract

Purpose: Roux-en-Y gastric bypass (RYGBP) is a mainstay of bariatric surgical therapy. A Gastro-Gastric Fistula (GGF) is an infrequent but potentially serious complication of gastric bypass, and clinicians often have difficulty establishing the diagnosis. We report a novel endoscopic technique of successful management of GGF using APC and endo-clips. Methods: A 31-year-old woman with a BMI of 44 underwent a laparoscopic divided ante-colic Roux-en-Y gastric bypass (RYGBP), with creation of a 30-cc gastric pouch. Her immediate post-operative course was unremarkable. She was discharged home on the 6th post-operative day. Two months later, she complained of persistent postprandial nausea and emesis. An upper GI series performed revealed a GGF, with preferential flow into the bypassed stomach (Fig. 1). Despite this finding, she has achieved a 70% excess weight loss. The patient had elected not to pursue revisional surgery. Upper Endoscopy was performed. No marginal ulcerations noted. GGF was identified at the cardia. Twice daily PPI's did not improve her symptoms. Two weeks later repeat endoscopy was perfomed. A guide-wire was passed through the fistula. Fluoroscopy confirmed the position of the cannula in the distal stomach pouch. APC of the fistula tract was done. Two Boston Scientific Resolution Clips were used to close the fistula after APC of the tract. The patient was sent home on twice daily PPI. Her symptoms improved. Repeat upper GI series three weeks later showed closure of GGF (Fig. 2). Results: Although a gastro-gastric fistula is currently an uncommon complication of RYGBP, historically GGF was one of the most common complications after undivided RYGBP, occurring in up to 50% of patients. This complication rapidly declined with the introduction of laparoscopic gastric bypass with an incidence ranging from 0–6%. Multiple factors likely to play a role in the formation of a GGF. Failure to completely transect the gastric pouch from the bypassed stomach, gastrojejunal anastomotic leak, anastomotic or marginal ulcerations, and obstruction of the Roux-limb distal to the anastomosis is few of the causes of formation of GGF. In patients with a clearly identifiable GGF on contrast study and/or endoscopy who demonstrate poor weight loss, revisional surgery should be considered. In patients with demonstrable GGF but good weight loss, PPI therapy should be used to treat symptoms. Conclusion: In symptomatic patients, as we have shown, obliterating the fistula tract using APC and closure of GGF using endo-clips should be considered safe and effective.