title: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Bariatric Institute and Division of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, 33331, USA.
authors.forename: Lester
authors.initials: L
authors.lastname: Carrodeguas
authors.forename: Samuel
authors.initials: S
authors.lastname: Szomstein
authors.forename: Flavia
authors.initials: F
authors.lastname: Soto
authors.forename: Oliver
authors.initials: O
authors.lastname: Whipple
authors.forename: Conrad
authors.initials: C
authors.lastname: Simpfendorfer
authors.forename: John Paul
authors.initials: JP
authors.lastname: Gonzalvo
authors.forename: Alexander
authors.initials: A
authors.lastname: Villares
authors.forename: Natan
authors.initials: N
authors.lastname: Zundel
authors.forename: Raul
authors.initials: R
authors.lastname: Rosenthal
mesh_terms: D015746:Abdominal Pain / Q000209:etiology; D000328:Adult; D000465:Algorithms; D000897:Anti-Ulcer Agents / Q000627:therapeutic use; D003287:Contrast Media; D003974:Diatrizoate Meglumine; D004322:Drainage; D004945:Esophagoscopy; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects*; D005747:Gastric Fistula / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D005773:Gastroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000209:etiology; D009767:Obesity, Morbid / Q000601:surgery*; D010288:Parenteral Nutrition; D054328:Proton Pump Inhibitors; D012086:Reoperation; D012146:Rest; D012189:Retrospective Studies; D013276:Stomach Ulcer / Q000175:diagnosis / Q000188:drug therapy; D013392:Sucralfate / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014839:Vomiting / Q000209:etiology
chemical_list: D000897:Anti-Ulcer Agents; D003287:Contrast Media; D054328:Proton Pump Inhibitors; D003974:Diatrizoate Meglumine; D013392:Sucralfate