Will You Lose Weight After A Gastrogastric Fistula Repair

Abstract

Gastro-gastric fistula is a communication between the gastric remnant and gastric pouch. It is a rare complexity of Roux-en-Y gastric featherbed. It is caused by anastomotic leak, marginal ulcers, distal obstacle or erosion from foreign body. In this case written report, we are presenting a successful laparoscopic repair of gastro-gastric fistula in a patient who presented with weight gain after initial loss.

INTRODUCTION

Currently, bariatric surgery offers the nearly sustained and meaning weight loss in the morbidly obese patients [1]. Indications for bariatric surgery are severe obesity with a body mass index (BMI) > forty or > 35 in the presence of weight-related comorbid disease [2].

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the almost commonly performed bariatric operation in the Usa [3]. Considering of the advantages of minimally invasive surgery information technology is now the preferred surgical approach [4]. Notwithstanding, the procedure is non without complications.

Major complications include leaks, anastomotic strictures, bowel obstruction, gastro-gastric and gastro-cutaneous fistulas [5].

Gastro-gastric fistula, a communication between the gastric pouch and gastric remnant, is a rare complexity of RYGB that tin can pb to weight regain, reflux and marginal ulceration.

Possible etiologies include technical complication due to incomplete sectionalization of the stomach during the creation of the pouch, or after a staple-line failure, developing a leak with resulting abscess, which then drains internally into the distal tummy forming the fistula [6]. We present a case of gastro-gastric fistula following gastric bypass at an exterior facility which was successfully managed laparoscopically at our institution.

CASE Written report

A 49-yr-onetime female person who was status post laparoscopic gastric bypass at an exterior facility in 2010 presented to our bariatric dispensary for evaluation. She lost 99 lb in 2 years after her gastric bypass but regained 43 lb in a couple of months prior to presentation. At the fourth dimension of evaluation, patient'due south BMI was 32. Upper gastrointestinal swallow report was negative for any acute abnormality (Fig. 1). Endoscopic gastroduodenoscopy (EGD) was performed which showed a communication between the gastric pouch and remnant stomach (Fig. 2). Gastric pouch was constitute to exist 5 cm from the GE junction.

Figure 1:

Upper GI study showing no evidence of leak.

Figure 2:

EGD showing the gastro-gastric fistula.

Patient was scheduled for laparoscopic repair of fistula. Intra-operatively gastro-gastric fistula was confirmed by insufflating air through gastric pouch while alimentary limb was clamped. Afterward confirmation, remnant stomach was mobilized and transected proximally forth with gastro-gastric fistula. Gastric pouch and comestible limb were protected.

Patient tolerated the procedure well and was successfully extubated at the end of the procedure. She was discharged on post-operative Day 2. On follow-upwardly, her BMI decreased from 32 to 28 in 3 months and she had no complaints related to the alimentary canal.

Give-and-take

The incidence of gastro-gastric fistula decreased as the REYGB technique was modified [7]. Currently, the incidence of gastro-gastric fistula ranges from 0 to half-dozen% of RYGBs [8–x].

It is a technical complexity that can be acquired by incomplete sectionalization of the stomach during the creation of the pouch particularly at the angle of His as the tum tin can hide in the intra-intestinal fat in that area. To avoid this, it is crucial to visualize the whole stomach.

It tin can also occur afterwards a staple-line failure, with resulting leak or abscess that can internally drain into the gastric remnant.

Cucchi et al. observed six patients with gastro-gastric fistulas. All patients had fever, tachycardia and abdominal pain. Less frequent symptoms were nausea, vomiting, fatigue and diarrhea, shoulder hurting, tachypnea and anorexia [8]. Gastro-gastric fistula can be diagnosed early in the post-operative menses when the patients fail to lose weight or belatedly when weight regain occur every bit patients lose the discomfort associated with gastric pouch distention.

The diagnosis can exist made using upper gastrointestinal contrast serial or CT with contrast flowing into the gastric remnant. While definitive study is upper endoscopy. Once diagnosed, gastro-gastric fistula is treated surgically, by laparoscopic or open surgery.

When safe, laparoscopic surgery is preferred over open surgery for treating gastro-gastric fistula resulting in resolution of symptoms and improved weight loss with acceptable morbidity compared with patients who underwent open surgery [eleven].

Laparoscopic surgery is easily performed when the gastro-gastric fistula is diagnosed early in the mail-operative catamenia [12]. But when diagnosed late, the surgical arroyo is more hard. When a patient present with weight regain after RYGB it is important to consider gastro-gastric fistula every bit a possible cause of weight regain.

ACKNOWLEDGMENT

We thank the bariatric team at our infirmary.

Conflict OF Involvement STATEMENT

None declared.

REFERENCES

one

Livingston

Obesity and its surgical management

Am J Surg

2002

;

184

103

–

two

National Institutes of Health Consensus Development Conference

Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference statement

Am J Clin Nutr

1992

;

615

–

iii

DeMaria

Sugerman

Kellum

Meador

Wolfe

Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity

Ann Surg

2002

;

235

640

–

seven

Lyass

Khalili

Cunneen

Fujita

Otsuka

Chopra

, et al. .

Radiological studies after laparoscopic Roux-en-Y gastric featherbed: routine or selective?

Am Surg

2004

;

918

–

Blachar

Federle

Pealer

Ikramuddin

Schauer

PR.

Gastrointestinal complications of laparoscopic Roux-en-Y gastric featherbed surgery: clinical and imaging findings

Radiology

2002

;

223

625

–

half dozen

Branco Filho

Kondo

West

Nassif

Garcia

Tirapelle

Dotti

Gastrogastric fistula: a possible complication of Roux-En-Y gastric featherbed

JSLS

2006

;

326

–

seven

Capella

RF.

Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction

Obes Surg

1999

;

–

Cucchi

Pories

MacDonald

Morgan

Gastrogastric fistulas. A complication of divided gastric bypass surgery

Ann Surg

1995

;

221

387

–

Carrodeguas

Szomstein

Due south

Soto

Whipple

Simpfendorfer

Gonzalvo

, et al. .

Management of gastrogastric fistulas after divided Roux-en-Y gastric featherbed surgery for morbid obesity: analysis of 1292 consecutive patients and review of literature

Surg Obes Relat Dis

2005

;

467

–

Gumbbs

Duffy

Bell

Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass

Surg Obes Relat Dis

2006

;

two

117

–

Khaitan

Van Sickle

Gonzalez

Lin

Ramshaw

Smith

Laparoscopic revision of bariatric procedures: is information technology feasible?

Am Surg

2005

;

–

Gould

Garren

Starling

JR.

Lessons learned from the first 100 cases in a new minimally invasive bariatric surgery plan

Obes Surg

2004

;

618

–

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