Gastrogastric Fistula Research Articles

The Gastric Remnant in Roux-en-Y Gastric Bypass: Challenges and Possibilities.

Laparoscopic Roux-en-Y gastric bypass (RYGB) is widely applied in the treatment of morbid obesity. Health personnel meeting these patients should thus be familiar with the potential clinical consequences of the modified anatomy induced by the surgery. After a RYGB, the stomach is left in situ after the closure of the upper part of the organ. This blind-ended gastric remnant may cause complications and surgical emergencies, but also opportunities for diagnostic and therapeutic intervention. The present review focuses on complications related to the gastric remnant including bleeding and acute dilatation in the early postoperative period and later adverse events such as gastroduodenal peptic disease, tumors, gastrogastric fistulas, and late dilatation. Opportunities offered by the remnant, including minimal invasive or open access for enteral nutrition, and therapeutic and diagnostic access to the bile ducts, the duodenum, and the gastric remnant, which is challenged by the modified anatomy, are discussed. Reversal of the gastric bypass and gastrointestinal reconstruction after esophageal resection have been commented on. The review aims to improve the awareness of issues related to the gastric remnant for physicians involved in the treatment and the follow-up of patients after a RYGB.

A154 - Laparoscopic Roux-en-Y gastric bypass (LRYGB) after Loop gastric bypass and gastro-gastric fistula and reversed jejunoileal bypass

A154 - Laparoscopic Roux-en-Y gastric bypass (LRYGB) after Loop gastric bypass and gastro-gastric fistula and reversed jejunoileal bypass

A152 - Laparoscopic repair of a recurrent GastroGastric fistula after failed Transgastric closure of fistula

A152 - Laparoscopic repair of a recurrent GastroGastric fistula after failed Transgastric closure of fistula

Controversies and Pitfalls of Imaging Patients Postoperative Bariatric Surgery

Bariatric surgery has become increasingly popular for treatment of morbid obesity. Imaging for diagnosis of postoperative complications is a challenge in this patient population. In this article, we provide an overview of the most important postoperative complications associated with bariatric surgery, viz. anastomotic leak, internal hernia, biliopancreatic limb obstruction, and gastrogastric fistula. We address the controversies in postoperative imaging of bariatric surgery patients, reviewing the available literature and supplement it with our experience. We also cover a few potential imaging pitfalls which need to be avoided.

Endoluminal closure of gastrogastric fistula

Gastrogastric fistulas have a reported incidence of 1.3%–12% after gastric bypass for treatment of morbid obesity. The fistula can occur as a result of incomplete division of the stomach or staple line dehiscence, in the setting of a chronic or perforated marginal ulcer, or as a sequela of staple line leak. In the acute setting, patients can present with tachycardia, fevers, and abdominal pain. However, the development of a gastrogastric fistula in a chronic setting is more subtle: Patients may experience weight regain, postprandial abdominal pain with associated marginal ulcers, and esophageal reflux. Management traditionally consists of surgical revision with associated morbidity [ [1] Corcelles R. Jamal M.H. Daigle C.R. Rogula T. Brethauer S.A. Schauer P.R. Surgical management of gastrogastric fistula. Surg Obes Relat Dis. 2015; 11: 1227-1232 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar ]. Here we report on a treatment option that consists of endoscopic intervention with complete closure of the fistula with added benefits of same-day surgery, decreased operative time, no incisions, and minimal morbidity [ 2 Kantsevoy S.V. Thuluvath P.J. Successful closure of a chronic refractory gastrocutaneous fistula with a new endoscopic suturing device (with video). Gastrointest Endosc. 2012; 75: 688-690 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar , 3 Kumar N. Thompson C.C. Transoral outlet reduction for therapy of weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc. Epub 2015 sep 5; Google Scholar ].

Multidetector CT imaging of bariatric surgical complications: a pictorial review.

The prevalence of obesity is increasing, along with the number of bariatric surgical procedures performed to treat obesity. Laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and laparoscopic gastric banding (GB) comprise the vast majority of procedures with SG now the dominant procedure in the USA. Although multidetector computed tomography (MDCT) is not always the examination of choice for a particular suspected complication, many of these patients present with non-specific abdominal symptoms and undergo MDCT evaluation as an initial diagnostic test. This pictorial essay will review and discuss the normal post-surgical bariatric appearance on MDCT, and the appearance of common and uncommon complications associated with the common bariatric procedures on MDCT with correlative imaging. SG complications include leak/abscess, hemorrhage, splenic injury, and portomesenteric thrombosis. RYGB complications include leak/abscess, gastrogastric fistula, small bowel obstruction, internal hernia, and intussusception. Although GB is waning in popularity, radiologists continue to see the legacy of these patients and complications include gastric prolapse, band erosion, and port/tubing mechanical failures. Awareness of the characteristic findings of bariatric complications on MDCT is critical, allowing for earlier recognition and prompt intervention.

A166 - Endoluminal Closure of Gastro-Gastric Fistula

Gastro-gastric fistulas (GGF) have a reported rate between 1.3% - 12% after gastric bypass for treatment of morbid obesity. The fistula occurs as a result of either incomplete division of the stomach, staple line migration or as a sequelea of staple line leak. In the acute setting, patients present with tachycardia, fevers, and abdominal pain. However, the development of a gastro-gastric fistula in a chronic setting is more subtle, where patients may experience weight gain, post-prandial abdominal pain with associated marginal ulcers, and esophageal reflux. Management traditionally consists of surgical revision with associated morbidity. Here we demonstrate a treatment option that consists of endoscopic intervention with complete closure of the fistula with added benefits of same day surgery, decreased operative time, no incisions and minimal morbidity.

A169 - Laparoscopic Revision of Chronic Marginal Ulcer and Bilateral Truncal Vagatomy

Bariatric surgery is the only proven and effective long term treatment for morbid obesity. In accredited centers, bariatric surgery is performed with very low mortality, morbidity and readmission rates. However, a small number of bariatric patients develop postoperative complications like marginal ulcers. The etiology of marginal ulcers following a Laparoscopic Roux en Y gastric Bypass (LRYGB) is a matter of debate. Many factors are believed to contribute to the development of marginal ulcers such as smoking, ischemia, foreign body reaction, gastro-gastric fistulas, large gastric pouches and tension at the anastomosis.

A171 - Bariatric Surgery Complications: Diagnosis and Management of The Gastrogastric Fistula

A171 - Bariatric Surgery Complications: Diagnosis and Management of The Gastrogastric Fistula

Endoscopic Repair of Gastrogastric Fistulas After Roux-en-Y Gastric Bypass

Introduction: Gastrogastric fistulas are a rare complication of Roux en Y gastric bypass. Several options exist for repair. Our goal was to present our experience with the use of an over the scope clip system for endoscopic intervention. This is a retrospective review from a university hospital where three patients have undergone endoscopic repair of gastrogastric (GG) fistulas using an over the scope clip (OTSC) system developed by OVESCOTM. Case Presentations: Patient 1, a 58 yo female, presented with increased food intake. She was found to have a GG fistula 2 months post Roux en Y bypass (RNY). Her postoperative course was complicated by a left subphrenic abscess and left empyema which necessitated a VATS procedure. Two fistulas were found at EGD, one of which measured 14 mm and the other 5 mm in diameter. Two hemoclips and one OTSC (12/6 GC) were applied to the larger defect and one hemoclip was applied to the smaller defect. Repeat upper GI series one month post EGD showed failure of fistula closure. Patient 2, a 69 yo female, presented with epigastric abdominal pain and was found to have a 4 mm GG fistula 34 months post RNY. She had lost ˜118lbs since bypass. On initial repair attempt the fistulous tract appeared to have closed after APC and hemoclip placement x 2, however the fistula was again noted on repeat upper GI series 4 months later. A follow up EGD was performed with successful OTSC deployment (12/6 GC). Patient 3, a 44 yo female, presented with epigastric abdominal pain, nausea, emesis, and weight gain and was found to have a 5 mm GG fistula 66 months post RNY. She had lost ˜ 435 lbs since bypass. Successful OTSC deployment was performed (12/6 GC). The patient experienced symptom relief on follow up. Discussion: The success of gastrogastric fistula repair using an OTSC system appeared to be influenced by several factors including size, acuity, and post operative complications. Smaller fistulas were closed with greater success. The time interval between bypass and fistula development seems to have influenced success as well with fistula closure achieved in patients with a mean development interval of 50 months. Small superficial mucosal tears, with no evidence of bleeding or perforation, were noted in the proximal esophagus in both successful cases. The use of an OTSC system represents a safe, minimally invasive strategy for endoscopic closure of gastrogastric fistulas ≤5 mm.Figure 1Figure 2Figure 3

Conversion from gastric bypass to sleeve gastrectomy for complications of gastric bypass.

Complications after gastric bypass (RYGB) are well documented. Reversal of RYGB is indicated in select cases but can lead to weight gain. Conversion from RYGB to sleeve gastrectomy (SG) has been proposed for correction of complications of RYGB without associated weight gain. However, little is known about outcomes after this procedure. To examine outcomes after conversion from RYGB to SG. University hospital. A retrospective study of patients who underwent RYGB to SG conversion was undertaken. Twelve patients underwent RYGB to SG conversion for refractory marginal ulceration, stricture, dumping, gastrogastric fistula, hypoglycemia, and failed weight loss. No deaths occurred. Four patients experienced 7 major complications, including portal vein thrombosis, bleeding, pancreatic leak, pulmonary embolus, seroma, anastomotic leak, and stricture. Two required reoperation, and 6 were readmitted within 30 days. Four required nasoenteric feeding postoperatively because of prolonged nausea. The complication of RYGB resolved in 11 of 12 patients. At 14.7 months, change in body mass index for all patients was a decrease of 2.2 kg/m(2). In 5 patients with morbid obesity at conversion, the change in body mass index was a decrease of 6.4 kg/m(2) at 19 months. Laparoscopic conversion from RYGB to SG is successful in resolving certain complications of RYGB and does not result in short-term weight gain. However, conversion has a high rate of major complications as well as a high rate of readmission and need for supplemental nutrition. Although conversion to SG may be appropriate in carefully-selected patients, other options for patients with severe chronic complications after RYGB should be considered.

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

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.

Late surgical complications after gastric by-pass: a literature review.

IntroductionGastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones.MethodLiterature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English.ResultsThere were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula.ConclusionKnowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.

EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach

ERCP is challenging in patients with Roux-en-Y gastric bypass. Using EUS to gain access to the excluded stomach and subsequently performing transcutaneous ERCP was described recently. We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). Single-center case series. Tertiary center with expertise in EUS-guided procedures. Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. A linear echoendoscope was used to access the excluded stomach. A LAMS was deployed over a wire to create a gastrogastric or jejunogastric fistula. A duodenoscope was then passed through the LAMS and conventional ERCP was performed. Technical and clinical success rates as well as adverse events. EUS-guided creation of a gastrogastric or jejunogastric fistula via placement of a LAMS was successful in all cases (100%). The ability to perform ERCP through the fashioned fistula during the index procedure was successful in 3 of 5 cases (60%). Two LAMS dislodgments requiring restenting were observed. No major adverse events were observed. No weight regain occurred. The median procedure time was 68.0 minutes. Small sample, single-institution experience. The internal EDGE procedure may offer a cost-effective, minimally invasive option for a common problem in a growing patient demographic. Further refinement of the technique is required to minimize adverse events. ( NCT01522573.).

Mo1535 Outcomes of Fistula Closure by Endoscopic Suturing: a Multi- Center Study

Mo1534 Extreme Endoscopy: a New Paradigm in Interventional Endoscopy Monkemuller Klaus*, Paul T. Kroner, Mark C. Phillips, Helmut Neumann, Ivan Jovanovic Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama, Birmingham, AL Introduction: Extreme endoscopy is a new discipline in interventional GI endoscopy. Previous data on extreme endoscopy comes from case reports. Aims: To report on the feasibility and outcomes of extreme endoscopy. Methods: Observational, retrospective study conducted at a tertiary care hospital during an 18-months period. All procedures were performed under general anesthesia. Extreme endoscopy comprises five key components: (i) use of multiple scopes or dual endoscope technique; (ii) use of various types of overtubes (OT), (iii) utilization of modified devices, (iv) use of fluoroscopy and, (v) necessity of utilizing a tool box with: wire cutter, glue, tape, foam (Endosponge). Singleor double balloon enteroscopy (SBE, DBE) was not defined as extreme endoscopy, unless the technique was utilized to perform a) endoscopic re-anastomosis of disrupted GI tract; b) PATENT (percutaneous assisted transprosthetic endoscopic therapy); c) SBEor DBE-rendezvousERCP; d) endoluminal stenting, e) removal of migrated SEMS from the small bowel. Additional exclusions: ESD or POEM cases (nZ45) and pancreatic necrosectomies (nZ28). Success was defined as resolution of the primary luminal problem. Results: 44 patients (23 females, 21 males, mean age 57 years, age range 32-83) with various types of complex primary, secondary or post-surgical anatomy endoluminal GI defects were studied. In 20 patients (45%) previous surgical, endoscopic or radiologic attempts at solving the problem had failed. In 11 patients (25%) there were no other interventional treatment options available. Interventions performed: PATENT (nZ3), endoscopic re-anastomosis of the disrupted GI tract (nZ4), Endosponge placement for drainage of huge cavities (nZ3), OT-assisted removal of mesh (nZ2), OT-assisted removal of migrated lap bands (nZ3), OT-assisted SEMS placement of the small bowel and/or colon (nZ8), combined closure of fistula or perforation and placement of direct endoscopic jejunostomy (nZ7), SBEor DBE ERCP with exchange of scope for slim cholangioscope to perform EHL (nZ4), rendezvous-DBE ERCP to place SEMS into the bile duct (nZ3) or to place plastic stents percutaneously under direct endoscopic view (nZ2), OT-assisted endoscopy allowing for ERCP or PEG placement in patients with esophageal stenosis (nZ3). The technical success was 87.8%. The mean procedure time was 35 minutes (range 45 min to 4 hours). There were no major adverse events associated with the procedures. Conclusions: This is the largest study reporting on extreme endoscopy. Albeit time consuming extreme endoscopic interventions lead to a resolution or remediation of complex endoluminal disorders in the majority of patients. It appears that extreme endoscopy may provide hope for patients in whom no other choices exist. Now multi-center studies in this topic are warranted. Mo1535 Outcomes of Fistula Closure by Endoscopic Suturing: a MultiCenter Study Saurabh S. Mukewar*, Nitin Kumar, Marc F. Catalano, Christopher C. Thompson, Christopher J. Gostout Gastroenterology, Mayo Clinic, Rochester, MN; Gastroenterology, Brigham and Women’s hospital, Boston, MA; Gastroenterology, GI Health Associates, Milwaukee, WI Background: Endoscopic closure of fistulas is desirable but remains a challenge, especially for gastrogastric fistulas. We report a multicenter experience using endoscopic suturing to close gastrointestinal fistulas. Methods: Electronic records at two academic centers and one private clinic were reviewed to identify patients who underwent sutured fistula closure (OverStitch, Apollo Endosurgery , Inc., Austin, Texas). Demographic, clinical variables and details of endoscopic procedure were recorded. Results: A total of 56 patients underwent single session fistula closure (26: Brigham and Women’s hospital; 21: Mayo Clinic and 9: GI associates, Milwaukee, WI). Mean age was 54 +/12.7 years. Gastrogastric fistula (29 (51.8%) was the most common fistula. 16 (28.6%) had a failed previous attempt at closure of fistula. Immediate success was seen in all cases [56 (100%)] and 17 (42.5%) had successful closure of fistulas as observed on endoscopy [18(45%)], imaging [13(32.5%)] or clinical [5(12.5%)] follow up. Gastrogastric fistulas had lower rates of closure [5/19 (26.3%)] compared to other fistulas [12/21 (57.1%)]. Data on subsequent procedures and outcomes was available from Mayo cohort. Out of 21 patients, 2 underwent surgery, 3 had no follow up imaging/endoscopy. 9/15 (60%) required repeat endoscopic procedures (range: 1 to 4) with successful outcome in 4/9 (44.5%) cases. Only one patient (1.8%) had abdominal pain requiring hospital admission. Conclusion: Single session suture closures of fistulas alone are safe and can be effective especially in known challenging cases. Sequential closures for persistent fistula warrants attention. Age* 53.9 +/Type of fistula Fistula sutures^ 2

Mo1566 Utility of Double Balloon Enteroscopy in Patients With Surgically Altered Bowel Anatomy After Bariatric Surgery

database were reviewed to collect data. Results: 25 patients (17 women/8 men, mean age 45.3 10.6 years) were included. Post-operative collections occured after sleeve gastrectomy in 20 patients and after gastric bypass in 5. A median of 48 days (range 5-1071) elapsed between initial surgery and transfistulary stenting. 11 patients were treated by transfistulary stenting as primary treatment, while 14 patients had previously failed treatment attempts with one or more endoscopic methods (endoprosthetics, clips and/or fistula plugs). Internal drainage was initially maintained by placement of 2 double pigtail stents (7 or 8.5 Fr ) in 21 patients or by one stent and a naso-cystic catheter in 4. In 5 patients, transfistulary stenting was combined with percutaneous drainage. No complication occurred during the initial drainage procedure. In 6 patients, trans-fistulary stenting was not successful and surgery was necessary. Clinical success was achieved in 19 patients (76%). In 7 successfully treated patients, stents are still in place after a median stenting duration of 102 days (range 41-1620) and no complication has occurred. In 4 patients with spontaneous stent migration, no complication has occurred after a median follow-up duration of 137.5 days (range 85-390). In 8 patients, the plastic stents have been removed after a median stent indwell duration of 186.3 days (range 24-773) and no complication has occurred after a median follow-up duration of 159.4 days (range 5-461). In these patients, stents were either removed electively (2 patients) or because of dysphagia or symptomatic stent-induced esophageal ulcerations (6 patients). Conclusions: Trans-fistulary drainage of post-bariatric abdominal collections is safe and is associated with high success rates. This technique seems promising and can be considered either in previously untreated patients when a collection is present and not properly drained percutaneously or after failure of other endoscopic treatments. Mo1566 Utility of Double Balloon Enteroscopy in Patients With Surgically Altered Bowel Anatomy After Bariatric Surgery Shabnam Sarker, Shajan Peter, Ivan Jovanovic, Helmut Neumann, Monkemuller Klaus* Basil I Hirschowitz Endoscopic Center of Excellence, University of Alabama, Birmingham, AL Background: Endoscopic investigation of the gastrointestinal (GI) luminal and pancreatobiliary tracts in patients with surgically-altered GI anatomy after bariatric surgery is challenging and often impossible. The advent of balloon-assisted enteroscopy (BAE) has increased our ability to navigate through the surgically altered bowel. Despite the existence of BAE since more than a decade there is few data available on it potential utility for evaluation post-obesity-surgery patients. Aims: To evaluate the diagnostic yield, success and complications rates of double-balloon enteroscopy (DBE) in consecutive patients with GI problems necessitating endoscopic evaluation. Materials and Methods: Single-center, observational, cohort study of consecutive patients with post-obesity-surgery undergoing DBE during a 24-months period. Patients’ demographics, procedure indications, findings, endoscopic interventions, and post-procedural recovery data were recorded. Results: A total of 435 DBE were performed at our institution during the 24-months study period. Sixty-five patients (14.9%) with post-obesity surgery were evaluated using DBE. The types of surgery were: RYGB, gastric sleeve, lap-band. The indications for DBE was obscure GI bleeding (OGIB) (nZ18), ERCP (nZ31), and evaluation of and abdominal pain or diarrhea (nZ10) and placement of direct feeding jejunostomy (nZ6). The excluded stomach could be reached in 87% of patients with Roux-en Y gastric bypass. The overall diagnostic yield of DBE-ERCP was 68% (stones, nZ7, sphincter stenosis, nZ6, bile leak, nZ4, bile duct stricture, nZ4, failed ERCP, nZ10). The yield of DBE for abdominal pain was 40% (nZ4: gastric erosions, gastro-gastric fistula, anastomotic stricture and erosions) and DBE for obscure GI bleeding (61%). Of the 18 patients with OGIB, 10 had active or a source of bleeding at the time of DBE. In all but one case, the bleeding was occurring at the site of the anastomosis, (hepaticojejunal, jejunojejunal, or gastrojejunal anastomosis). Of these patients 4 patients had arteriovenous malformations at the anastomotic site, 5 had ulcers or erosions, and 2 were bleeding secondary to Dieulafoy’s lesions. A total of one complication (3%) was observed (small bowel perforation after application of argon plasma coagulation to the jejunojejunal anastomosis). One patient had actively bleeding duodenal ulcer at the excluded bulb, which was treated with injection and clip. Conclusions: DBE is a feasible and relatively safe technique to evaluate the small intestines, stomach and biliary tract and associated with reasonably high diagnostic and therapeutic yield in patients with surgically altered bowel anatomy in the setting of bariatric surgery.

Surgical management of gastrogastric fistula

BackgroundGastrogastric fistula (GGF) is a rare complication after Roux-en-Y gastric bypass (RYGB) that can be challenging to treat. ObjectiveThe aim of this study is to examine our surgical experience in the management of GGF after RYGB. SettingAcademic center, United States. MethodsWe report a consecutive series of 36 patients who underwent surgery for GGF at our institution between 2005 and 2013. ResultsThe cohort had a mean age of 48.0±10.8 years, mean body mass index (BMI) of 34.6±11.3 kg/m2, and an average number of 5.0±2.0 co-morbidities at the time of GGF revision. Of the 36 patients, 16 (44.4%) had previous open RYGB. Endoscopy confirmed GGF in 26 patients (72.2%), whereas upper gastrointestinal (GI) series indicated GGF in 21 of 30 cases (70.0%). The GGF surgery was on average 6.4±3.8 years after the primary procedure. All patients underwent surgical management either in the form of a redo gastrojejunal anastomosis with excision of fistula (77.7%) or a remnant gastrectomy with excision of fistula (22.2%). Mean operative time, blood loss, and length of stay were 248.4±103.3 minutes, 232.7±270.2 mL, and 8.5±8.6 days, respectively. One major intraoperative and 6 early postoperative complications occurred. After a mean follow-up of 38.4±30.0 months, the mean BMI was 35.5±6.2 kg/m2 in patients with weight regain before GGF revision (P<.05) versus 25.0±6.1 kg/m2 in patients without weight regain (P = .7). ConclusionGGF is a rare complication of RYGB. Surgical treatment should be tailored to the presenting symptoms and associated anatomic abnormality. Anastomotic revisions are associated with higher complication rates.

Laparoscopic Gastric Bypass Revision

Gastrogastric fistula is a rare complication following a roux-en-y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, reflux, poor weight loss, and weight regain. Etiologies include postoperative Roux-en-Y gastric bypass leaks, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of a foreign body. Diagnosis is made through upper gastrointestinal contrast radiography or CT scan and endoscopy. Barium contrast radiography is particularly useful and is the preferred initial study method for the detection of staple-line dehiscence, which may be small and overlooked during endoscopy. Once identified, a gastrogastric fistula may be treated surgically with remnant gastrectomy or gastrojejunostomy revision. Here, we present a case of a female patient status post Roux-en-Y gastric bypass surgery who presented with abdominal pain. Upon endoscopy, she was noted to have an inflamed gastric pouch and a gastogastric fistula. A laparoscopic gastric bypass revision was done to divide the gastrogastric fistula and to separate the gastric pouch from the gastric remnant in order to alleviate the inflamed gastric pouch and prevent further ulcer formation.

Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass

BackgroundMarginal ulcers (MUs) are potentially complex complications after Roux-en-Y gastric bypass. Although most resolve with medical management, some require surgical intervention. Many surgical options exist, but there is no standardized approach, and few reports of outcomes have been documented in the literature. The objective of this study was to determine the outcomes of surgical management of marginal ulcers. MethodsData from all patients who underwent surgical intervention between 2004 and 2012 for treatment of MU after previous Roux-en-Y gastric bypass were reviewed. ResultsTwelve patients with MUs underwent reoperation. Nine patients had associated gastrogastric fistulae (75%). The median time to reoperation was 43 months. Ten patients underwent subtotal gastrectomy, of which 9 had a revision of the gastrojejunal anastomosis and 1 did not. One underwent total gastrectomy with esophagojejunal anastomosis for ulcer after previous revisional partial gastrectomy, and 1 patient underwent video-assisted thoracoscopic truncal vagotomy for persistent ulcer-related bleeding in the early postoperative period. Three patients (25%) experienced postoperative complications associated with revisional surgery requiring reoperation. At median follow-up time of 35 months, 7 patients (58%) had chronic abdominal pain, and 4 patients (33%) had intermittent diarrhea. Three patients (25%) were lost to recent follow-up. None had recurrence of MU. ConclusionPatients can undergo one of several available surgical interventions, including laparoscopic subtotal gastrectomy with gastrojejunostomy revision. Though this appears to offer definitive treatment of MU, its benefits must be weighed against the increased risk of significant postoperative complications and chronic symptoms related to revisional surgery.

Successful Closure of a Suture Line Leak Following Remnant Gastrectomy in a Patient With Gastrogastric Fistula Using an Over-the-Scope Clip

Introduction: In the past, treatment of gastrointestinal leaks was primarily surgical. Recently, endoscopic over the scope clip (OTSC) has been used to treat these defects. We report a case of a suture line leak following remnant gastrectomy that was successfully closed using an OTSC. Remnant gastrectomy was done to close a fistula that developed between the stomach pouch and the remnant stomach in this patient who had a remote history of gastric bypass. Case Report: Fifty-year-old white female who underwent a gastric bypass with a revision in 1998 developed gastrogastric fistula in 2013. Laparoscopic excision of the remnant stomach was done to close the fistula. She presented with fever and left sided chest pain 2 weeks after surgery. Upper GI series revealed extravasation of contrast from the stomach into the left upper abdomen. CT abdomen revealed an abscess in the left upper abdomen and left sided pleural effusion which were drained. EGD revealed 3 openings in the stomach pouch. The largest of these openings measured 10 mm through which the catheter draining the abscess was visible. Two 10 mm OTSCs were deployed successfully closing these openings. Follow-up CT abdomen 1 month later showed resolution of the abscess and no evidence of leak. Patient felt well at 5 months follow-up. Discussion: OTSC is a new endoscopic device that has been used for closing gastrointestinal leaks. Most of the reported cases of OTSC use for leak are for the lower GI tract. There are few case reports of OTSC use in upper GI leaks mainly for esophagogastric, gastroenteric anastomotic leaks and suture dehiscence following sleeve gastrectomy. We report the first case of suture line leak following remnant gastrectomy that was successfully closed using OTSCs. Our case was also unique in that there were 3 sites of leak that were successfully closed using 2 OTSCs in one session. Thus, OTSC can be a less invasive and cost effective leak repair technique compared to surgery in patients with a high risk of recurrence. Success rate of OTSC for anastomotic leak is lower (50-100%) than for perforation or bleeding (71-100%). Very early leaks occurirng within a week, leak size of 10 to 30 mm and prior abscess drainage are associated with successful closure of leaks. Our case reiterates this fact.Figure 1: OTSC placement.