Tags

Type your tag names separated by a space and hit enter

Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature.

Abstract

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure.

METHODS

We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery.

RESULTS

The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically.

CONCLUSION

Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.

Links

  • Publisher Full Text
  • Authors+Show Affiliations

    ,

    Bariatric Institute and Division of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, 33331, USA.

    , , , , , , ,

    Source

    MeSH

    Abdominal Pain
    Adult
    Algorithms
    Anti-Ulcer Agents
    Contrast Media
    Diatrizoate Meglumine
    Drainage
    Esophagoscopy
    Female
    Follow-Up Studies
    Gastric Bypass
    Gastric Fistula
    Gastroscopy
    Humans
    Male
    Middle Aged
    Nausea
    Obesity, Morbid
    Parenteral Nutrition
    Proton Pump Inhibitors
    Reoperation
    Rest
    Retrospective Studies
    Stomach Ulcer
    Sucralfate
    Tomography, X-Ray Computed
    Treatment Outcome
    Vomiting

    Pub Type(s)

    Journal Article
    Review

    Language

    eng

    PubMed ID

    16925272

    Citation

    Carrodeguas, Lester, et al. "Management of Gastrogastric Fistulas After Divided Roux-en-Y Gastric Bypass Surgery for Morbid Obesity: Analysis of 1,292 Consecutive Patients and Review of Literature." Surgery for Obesity and Related Diseases : Official Journal of the American Society for Bariatric Surgery, vol. 1, no. 5, 2005, pp. 467-74.
    Carrodeguas L, Szomstein S, Soto F, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005;1(5):467-74.
    Carrodeguas, L., Szomstein, S., Soto, F., Whipple, O., Simpfendorfer, C., Gonzalvo, J. P., ... Rosenthal, R. (2005). Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surgery for Obesity and Related Diseases : Official Journal of the American Society for Bariatric Surgery, 1(5), pp. 467-74.
    Carrodeguas L, et al. Management of Gastrogastric Fistulas After Divided Roux-en-Y Gastric Bypass Surgery for Morbid Obesity: Analysis of 1,292 Consecutive Patients and Review of Literature. Surg Obes Relat Dis. 2005;1(5):467-74. PubMed PMID: 16925272.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. AU - Carrodeguas,Lester, AU - Szomstein,Samuel, AU - Soto,Flavia, AU - Whipple,Oliver, AU - Simpfendorfer,Conrad, AU - Gonzalvo,John Paul, AU - Villares,Alexander, AU - Zundel,Natan, AU - Rosenthal,Raul, Y1 - 2005/08/31/ PY - 2005/02/16/received PY - 2005/06/24/revised PY - 2005/07/07/accepted PY - 2006/8/24/pubmed PY - 2006/10/13/medline PY - 2006/8/24/entrez SP - 467 EP - 74 JF - Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery JO - Surg Obes Relat Dis VL - 1 IS - 5 N2 - BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure. METHODS: We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery. RESULTS: The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically. CONCLUSION: Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence. SN - 1550-7289 UR - https://www.unboundmedicine.com/medline/citation/16925272/Management_of_gastrogastric_fistulas_after_divided_Roux_en_Y_gastric_bypass_surgery_for_morbid_obesity:_analysis_of_1292_consecutive_patients_and_review_of_literature_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1550-7289(05)00601-5 DB - PRIME DP - Unbound Medicine ER -