Original article
Classification, surgical management and outcomes of patients with gastrogastric fistula after Roux-En-Y gastric bypass

https://doi.org/10.1016/j.soard.2016.09.027Get rights and content

Abstract

Background

Gastrogastric fistula (GGF) is a known complication after Roux-en-Y gastric bypass that can lead to marginal ulceration (MU) and failure of weight loss.

Objectives

To describe our experience with GGF management and propose a classification of GGF based on its anatomic location.

Setting

University hospital, France.

Methods

After internal review board approval, data from all patients with a GGF were reviewed. GGF was classified as type 1 when located in the proximal part of the gastric pouch and type 2 when located near the gastrojejunostomy.

Results

Nine patients developed a GGF (.5%). GGF symptoms included epigastric pain (78%), vomiting (11%), gastrointestinal bleeding (11%), and weight regain (44%). Upper contrast study identified GGF in all patients. Upper endoscopy confirmed GGF in 6 patients, all with type 2. Eight patients required revisional surgery. Patients with type 1 GGF (n = 3) had excision of the fistulous tract. Patients with type 2 GGF (n = 5) had associated revision of the gastrojejunostomy. Mean operative time was significantly longer for type 2 GGF. The mean follow-up was 43 months, with no patient lost. One patient developed a recurrent MU requiring iterative revision. After that, all revisional patients were symptom free and the mean body mass index was 35.3±9.5 kg/m².

Conclusion

Weight regain and epigastric pain with or without associated MU are the most common signs of GGF. Combining upper gastrointestinal endoscopy and contrast study is the best method to confirm the diagnosis. Surgical treatment should be tailored to both GGF location and status of the gastrojejunostomy. Based on its anatomic location, GGF classification could serve as a working basis to compare different surgical approaches.

Section snippets

Methods

From November 2000 to January 2015 all patients who underwent laparoscopic RYGB were entered in a prospective database. After internal review board approval, we retrospectively reviewed data of all patients who were diagnosed with GGF. Data abstracted for analysis included patient characteristics, presenting symptoms, initial diagnostic studies, time from surgery to diagnosis, and time to revisional surgery. Moreover, we retrospectively searched all signs that could be symptomatic of a leak,

Results

During the study period, 1900 consecutive patients underwent divided RYGB; 1890 were completed laparoscopically and 10 converted to open. Nine patients developed a GGF (.5%). Demographic data are detailed in Table 1. Among the patients, one previously smoked, one had previous surgery for craniopharyngioma, and one had been converted to open RYGB. None had had preoperative Helicobacter pylori infection, and none used nonsteroidal anti-inflammatory drugs. One had developed a postoperative gastric

Discussion

In our series of 1900 consecutive patients who had divided RYGB, 9 developed a GGF (.5%), a relatively low incidence compared with others’ series [2], [3], [4]. However, the true incidence in most studies, including our own, are probably underestimated, as asymptomatic patients can achieve good durable weight loss [9], [10], [11]. Pathogenesis of GGF after divided RYGB is not clearly understood. Various causes have been advocated, such as failure of complete gastric transection, foreign body

Conclusion

Gastrogastric fistula is a rare complication after divided RYGB. Weight regain and epigastric pain with or without marginal ulcer are the most common presenting symptoms. Diagnosis can be challenging, but combining UGI endoscopy and contrast study is the best method to confirm the diagnosis. Surgical treatment should be tailored to both location of the GGF and status of the gastrojejunostomy, but anastomotic revision is associated with higher complication rates. GGF classification, based on its

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

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