Gastrogastric Fistula: It May Not be as Bad as it Sounds!!!
Abstract & Commentary
By Amir Mehran, MD, FACS, Assistant Clinical Professor of Surgery; Director, Bariatric Surgery, Section for Minimally Invasive and Bariatric Surgery, Department of Surgery, UCLA. Dr. Mehran reports no financial relationships relevant to this field of study.
Synopsis: Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB.
Source: Carrodeguas L, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: Analysis of 1292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005;1:467-474.
The comment, "there is contrast in the gastric remnant" was the last thing I expected to hear after my patient in the ER had a CT scan performed for abdominal pain. This cannot be a gastrogastric fistula (GGF), could it? After all, she was only 2 weeks postop from an uncomplicated, fully-transected laparoscopic Roux-en-Y gastric bypass (LRYGB). Ok, so she ignored postoperative instructions, ate a very spicy semi-solid lunch, developed immediate severe abdominal pain, and did not report it for 4 days. But a GGF this early? How did this happen, and what do I do now?
GGF is a well-known complication of the RYGB, occurring in 1-6% of cases. Its exact incidence, however, is unknown, as a significant number of patients remain asymptomatic. It is believed that the incidence has declined over the years. This has been attributed to the modification of the surgical technique where, in contrast to the past, the stomach is now completely transected rather than just stapled off in continuity. The etiology of GGF includes contained anastomotic leaks, marginal ulcers ± perforation, foreign body erosion, incomplete gastric division at original operation, and possible gastric wall tissue migration.1 The typical presenting symptoms, if any, are abdominal pain, intractable marginal ulcers secondary to acid backwash, and weight regain secondary to loss of restriction. Whereas most patients are managed conservatively, some do require more aggressive treatment modalities, either endoscopic or surgical. The former have included various plugs, medical glue, endoscopic clips, or suturing techniques. Depending on the etiology and size of the GGF, these techniques have had variable success rates.
One surgical approach has been published by Roberts and colleagues from Yale University.2 In one patient, a gastrotomy was made in the gastric remnant, followed by endoscopic introduction of pneumogastrium and transgastric suturing of the GGF. However, the follow-up was only 18 months, and there have been no other similar reports.
The Bariatric Surgery Institute at the Cleveland Clinic Florida has published the 2 most detailed papers about GGF and its surgical management.1,3 In 2005, the authors presented their experience with over 1200 patients. They identified GGFs in 15 (1.2%) of these subjects. The mean time to GGF diagnosis was 80 days, and ranged from 3 days to one year postop. Abdominal pain and nausea or vomiting were the most common symptoms, followed by weight regain. Imaging and endoscopic studies were confirmatory in all patients. Of interest, 4 patients had a known postoperative gastrojejunostomy leak that had been treated conservatively. GGF was associated with marginal ulcers in 8 of these subjects, most of whom responded to medical therapy (proton pump inhibitor and sucralfate). The authors also presented a concise treatment algorithm for GGF, and emphasized the need for aggressive follow-up to include gastrointestinal imaging and endoscopy for the presence of any abdominal pain symptoms or weight regain.
In a follow-up paper published recently,3 the same group presented their unique surgical approach to the management of GGF in 15 patients who failed conservative management. In the laparoscopic remnant gastrectomy, the fistula tract was transected with an endoscopic stapler, the pouch was trimmed, if necessary, and finally the gastric remnant was excised and removed. Cho and colleagues believe that the final step is very necessary. The number of gastric-producing cells is reduced, decreasing the odds of pouch acid production, and hence, future marginal ulcerations and strictures. Furthermore, this technique prevents future GGF formation by removing inflammatory tissue from the current GGF basin, reducing the possibility of gastric wall migration or new GGF formation. Cho et al do point out several flaws in their study, namely the small number of patients, short follow-up period, and possibility of future complications from remnant gastrectomy.
Commentary
So how did we manage our GGF patient? She was placed on a high protein liquid diet, sucralfate every 3 to 4 hours, and a proton pump inhibitor twice daily. Her pain symptoms resolved within 48 hours and, at 2 weeks, she remains pain free and is losing weight. We are only debating on whether we need to restudy her at any point with an imaging modality, and if so, when?
References
1. Carrodeguas L, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: Analysis of 1292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005;1:467-474.
2. Roberts, KE, et al. Laparoscopic transgastric repair of a gastrogastric fistula after gastric bypass: A novel technique. Surg Innov. 2007;14:18-23.
3. Cho M, et al. Laparoscopic remnant gastrectomy: A novel approach to gastrogastric fistula after Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg. 2007;204:617-624.
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