Laparoscopic treatment of gastrogastric fistulas after gastric bypass

Gastrogastric fistula (GGF) is a rare complication that occurs after a divided Roux-en-Y gastric bypass (RYGBP). The incidence can be as high as 49% in patients who undergo non-divided or partially divided RYGBP. This is the case of a 33-year-old female patient who benefited of a gastric bypass 4 months earlier. After the procedure, the patient suffered from dysphagia. During preoperative work-up, a gastrogastric fistula was discovered. This video shows the laparoscopic treatment of the gastrogastric fistula.

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Laparoscopic treatment of gastrogastric fistulas after gastric bypass

Authors

M Vix, D Mutter, J Marescaux

Abstract

Gastrogastric fistula (GGF) is a rare complication that occurs after a divided Roux-en-Y gastric bypass (RYGBP). The incidence can be as high as 49% in patients who undergo non-divided or partially divided RYGBP. This is the case of a 33-year-old female patient who benefited of a gastric bypass 4 months earlier. After the procedure, the patient suffered from dysphagia. During preoperative work-up, a gastrogastric fistula was discovered. This video shows the laparoscopic treatment of the gastrogastric fistula.

Classification

complex cases

Keywords

Laparoscopic treatment, gastrogastric fistulas after gastric bypass

Media type

Surgical video

Duration

10'36''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2587.htm

Laparoscopic treatment of gastrogastric fistulas after gastric bypass

1. Clinical case presentation 00'17''

This young 33-year-old patient benefited 4 months ago of a gastric bypass for morbid obesity. She had a BMI of 47 to begin with, and in 4 months, the patient quickly lost 12 BMI points. The patient complained of dysphagia and a gastroscopic dilatation was performed 3 months after the procedure. During the check-up, we notice a gastro-gastric fistula located between the superior part of the stomach and the stomach’s remnant.

2. Freeing of adhesions 00'51''

We re-use the various trocar orifices and we resect a few adhesions between the liver and the omentum. Gradually, the dissection is performed in order to be able to retract the liver. The liver is steatotic and extremely fragile as the patient suffers from undernourishment caused by her dysphagia. The alimentary loop is identified and is dissected free of its adhesions. We notice that the superior portion of the alimentary loop has indurated, and that it is therefore certainly the location of the fistula. The gastrojejunal montage is dissected of its hepatic adhesions. The dissection is performed very carefully in order to identify the various organs. A dissection is performed behind the surgical montage to fully understand which digestive segments are implicated.

3. Identification of fistulous area 02'24''

The fistula appears to be in this region, a dissection between the montage and the liver is then performed in order to better manipulate the gastrojejunal anastomosis. A posterior freeing is performed.

4. Intraoperative endoscopic control 03'13''

To identify the various digestive segments, an endoscopy is performed. Here the endoscope passes through the alimentary loop. The fistula is located between the biliary loop and the stomach’s remnant.

5. Stomach division 03'35''

We then decide to divide the stomach in two and to keep the antral portion. The dissection continues under the stomach to free its lower portion. Here we can see a dissection in contact to the lesser curvature. The dissection is performed very carefully because of the very dense adhesions and to avoid breaking a digestive viscera. The adhesions are extremely dense: they are literally sealing the organs together. The fistulous area is sufficiently freed in order to better understand the mechanism. The lower portion of the stomach inflates with the gas insufflation performed by the gastroscopy, corroborating the gastrogastric fistula. We then decide to perform a division between the antrum and the fundus in order to entirely free the lower portion of the stomach using a green cartridge Endo-GIA linear stapler. To complete this division, a second firing is needed. In that way, the antral section of the stomach is completely isolated; only the fundic portion in contact with the fistula now remains. A dissection will therefore be performed along the greater curvature to bring down all of the fundic pouch. This dissection must be performed behind the mounted loop. The laparoscopic approach is particularly interesting here as it allows to easily view the dissection. The greater curvature is completely freed by freeing its omental adhesions, followed by a dissection in contact to the short vessels. The previous stapling line is uncovered here: it is the separation line between the superior gastric pouch and the stomach’s remnant. All the adhesions are divided. The dissection is carried out carefully as we are once again approaching the fistulous area, here by going through the posterior part. The gastric pouch can in that way be entirely brought caudally; the only contact between the stomach’s remnant and the gastric pouch is this fistula. The stomach is opened in order to view the fistula’s lumen from inside the stomach. A gastroscopy is performed at the same time, and it is that approach that allows to identify the fistula’s orifice, measuring under 2mm in diameter.

6. Fistula closure 08'40''

We then decide to use a green cartridge Endo-GIA linear stapler to divide the remnant gastric pouch in order to close this fistula. We perform a hemostatic running suture on the antral section’s stapling line. This antral portion will also be re-approximated using a gastrotomy probe in order to allow rapid enteral feeding, and this even if a fistula should appear on the superior section of the montage. The fistulous area is protected by a blade. Postoperatively, the patient re-activated her fistula and a covered prosthesis was placed endoscopically, allowing for a rapid receding and for oral food intake to resume quickly.