title: Laparoscopic remnant gastrectomy as a novel approach for treatment of gastrogastric fistula.
abstract: BACKGROUND
  Gastrogastric fistula (GGF) is a rare complication after divided Roux-en-Y gastric bypass (RYGBP). The incidence can be as high as 49% in patients who undergo nondivided or partially divided RYGBP. We have previously reported a GGF rate of 1.5% after divided RYGBP. Remnant gastrectomy has been advocated by our group as a treatment option for this complication. We report our initial experience using the laparoscopic approach.
  
  
  METHODS
  After IRB approval and following HIPAA guidelines, we conducted a retrospective review of prospectively collected database of 1,796 patients who underwent RYGB from 2001 and to 2008 at the Bariatric and Metabolic Institute. Data included mean time to laparoscopic remnant gastrectomy (LRG), mean length of hospital stay, follow-up period after laparoscopic remnant gastrectomy, rate of conversion, type of procedure performed, and early and late postoperative complications.
  
  
  RESULTS
  Twenty-one (1.1%) patients have been diagnosed with GGF; 11 more patients were admitted with GGF after undergoing initial RYGB at another institution. All patients (n = 32) were initially treated with sucralfate and proton pump inhibitors, and 22 of 32 patients eventually underwent LRG: 1 underwent fistulectomy, 1 underwent conversion of vertical banded gastroplasty to RYGB, and the remaining 8 patients have undergone only medical treatment. The mean time to LRG was 9 months from the time of diagnosis of GGF. Two of the 22 patients had conversion to an open approach: one because of a loss of poor visual surgical field resulting from excessive intraluminal air from intraoperative endoscopy and the other as a result of the inability to understand the anatomy laparoscopically. Three of the 22 patients (13%) underwent LRG and redo gastrojejunostomy because of a stenosed gastrojejunostomy. The mean hospital stay after LRG was 4.7 (range, 3-8) days. Early postoperative complications included intra-abdominal bleeding, pneumonia, wound infections, and fever of unknown origin. Late complications included intra-abdominal abscess, wound infections, fever, and food impactation. The follow-up period after LRG was an average of 4 (range, 1-11) months. During the follow-up period, there was no evidence of marginal ulceration, bleeding, abdominal pain, or recurrence of the GGF in any patient.
  
  
  CONCLUSIONS
  Laparoscopic remnant gastrectomy seems to be a safe and effective treatment option for patients with GGF after RYGBP.
authors.affiliation: The Bariatric and Metabolic Institute, Section of Minimally Invasive and Endoscopic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA.
authors.forename: Jayaraj
authors.initials: J
authors.lastname: Salimath
authors.forename: Raul J
authors.initials: RJ
authors.lastname: Rosenthal
authors.forename: Samuel
authors.initials: S
authors.lastname: Szomstein
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000379:methods*; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D005747:Gastric Fistula / Q000209:etiology / Q000601:surgery*; D018530:Gastric Stump / Q000601:surgery*; D005773:Gastroscopy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000175:diagnosis / Q000601:surgery; D011183:Postoperative Complications / Q000175:diagnosis / Q000601:surgery; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome