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Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass.
Surg Obes Relat Dis. 2006 Mar-Apr; 2(2):117-21.SO

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/m2 vs 51.4 kg/m2). 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.

Authors+Show Affiliations

Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06510, USA.No affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

16925334

Citation

Gumbs, Andrew A., et al. "Management of Gastrogastric Fistula After Laparoscopic Roux-en-Y Gastric Bypass." Surgery for Obesity and Related Diseases : Official Journal of the American Society for Bariatric Surgery, vol. 2, no. 2, 2006, pp. 117-21.
Gumbs AA, Duffy AJ, Bell RL. Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006;2(2):117-21.
Gumbs, A. A., Duffy, A. J., & Bell, R. L. (2006). Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass. Surgery for Obesity and Related Diseases : Official Journal of the American Society for Bariatric Surgery, 2(2), 117-21.
Gumbs AA, Duffy AJ, Bell RL. Management of Gastrogastric Fistula After Laparoscopic Roux-en-Y Gastric Bypass. Surg Obes Relat Dis. 2006 Mar-Apr;2(2):117-21. PubMed PMID: 16925334.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass. AU - Gumbs,Andrew A, AU - Duffy,Andrew J, AU - Bell,Robert L, Y1 - 2006/02/28/ PY - 2005/10/25/received PY - 2005/12/07/revised PY - 2005/12/17/accepted PY - 2006/8/24/pubmed PY - 2006/9/29/medline PY - 2006/8/24/entrez SP - 117 EP - 21 JF - Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery JO - Surg Obes Relat Dis VL - 2 IS - 2 N2 - 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/m2 vs 51.4 kg/m2). 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. SN - 1550-7289 UR - https://www.unboundmedicine.com/medline/citation/16925334/Management_of_gastrogastric_fistula_after_laparoscopic_Roux_en_Y_gastric_bypass_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1550-7289(05)01034-8 DB - PRIME DP - Unbound Medicine ER -