Surgical management of gastro-gastric fistula after divided laparoscopic Roux-en-Y gastric bypass for morbid obesity

Background Gastro-gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial. Methods A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006. Results Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3-27). Morbidity in six patients (25%) was caused by pneumonia, n= 2; wound infection, n= 2; staple-line bleed, n= 1; and subcapsular splenic hematoma, n= 1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients. Conclusion Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.