Classification, surgical management and outcomes of patients with gastrogastric fistula after Roux-En-Y gastric bypass

Abstract

Background: Gastrogastric fistula (GGF) is a known complication after Roux-en-Y gastric bypass that can lead to marginal ulceration (MU) and failure of weight loss.

Objectives: To describe our experience with GGF management and propose a classification of GGF based on its anatomic location.

Setting: University hospital, France.

Methods: After internal review board approval, data from all patients with a GGF were reviewed. GGF was classified as type 1 when located in the proximal part of the gastric pouch and type 2 when located near the gastrojejunostomy.

Results: Nine patients developed a GGF (.5%). GGF symptoms included epigastric pain (78%), vomiting (11%), gastrointestinal bleeding (11%), and weight regain (44%). Upper contrast study identified GGF in all patients. Upper endoscopy confirmed GGF in 6 patients, all with type 2. Eight patients required revisional surgery. Patients with type 1 GGF (n = 3) had excision of the fistulous tract. Patients with type 2 GGF (n = 5) had associated revision of the gastrojejunostomy. Mean operative time was significantly longer for type 2 GGF. The mean follow-up was 43 months, with no patient lost. One patient developed a recurrent MU requiring iterative revision. After that, all revisional patients were symptom free and the mean body mass index was 35.3±9.5 kg/m².

Conclusion: Weight regain and epigastric pain with or without associated MU are the most common signs of GGF. Combining upper gastrointestinal endoscopy and contrast study is the best method to confirm the diagnosis. Surgical treatment should be tailored to both GGF location and status of the gastrojejunostomy. Based on its anatomic location, GGF classification could serve as a working basis to compare different surgical approaches.

Keywords: Complications; Gastric bypass; Gastrogastric fistula; Marginal ulcer; Revisional surgery; Weight regain.