Laparoscopic transgastric repair of a gastrogastric fistula after gastric bypass: a novel technique

Gastrogastric fistulas are an uncommon complication following laparoscopic Roux-Y gastric bypass surgery (LRYGB) and may be caused by staple-line dehiscence or leak. Described here is a novel technique to treat these fistulae via a laparoscopic transgastric approach and closure of the fistulous tract with an Endo Stitch device. The 33-year-old patient, post LRYGB in 2002, with documented gastrogastric fistula, had failed non-operative management. A transoral endoscope was passed into the cephalad portion of the gastrogastric fistula; a glidewire was passed from the gastric pouch into the gastric remnant. Laparoscopically, 2 gastrotomies were made and a "pneumogastrium" created with carbon dioxide. Under direct, transgastric visualization, the distal portion of the gastrogastric fistula was closed using an Endo Stitch device. This technique is safe and reproducible when performed by an experienced laparoscopic surgeon and could be modified for other scenarios requiring alternate access to the stomach.     

Utility of Divided Omentum for Preventing Complications Associated with Laparoscopic Gastric Bypass

Background Laparoscopic Roux-en-Y gastric bypass has emerged as a standard surgical treatment for morbid obesity. However, prevention of postoperative complications associated with bariatric surgery is an important consideration. Methods To reduce postoperative complications and achieve adequate body weight loss, we introduce a simple procedure using a divided omentum during laparoscopic Roux-en-Y gastric bypass. The actual aim of this procedure is to prevent leakage from the gastric pouch or anastomosis and the gastro-gastric fistula because of reentry of the alimentary tract. Between February 2002 and April 2007, we performed laparoscopic Roux-en-Y gastric bypass for morbid obesity in 94 patients. In the most recent 83 cases, our simple procedure using a divided omentum was employed. Results These patients comprised 20 males and 63 females, with a mean age of 38 years, and a mean body mass index of 44.1 kg/m². At surgery, the omentum is routinely divided using laparoscopic coagulating shears before performing gastrojejunostomy to reduce the tension on the anastomosis caused by the route of reconstruction. After performing hand-sewn gastrojejunostomy, the left side of the divided omentum is moved cranially and interposed between the gastric pouch and the excluded stomach. The omentum is then sutured from the posterior aspect of the gastric pouch to the anterior side of the anastomosis. Conclusion Our procedure using a divided omentum during bariatric surgery is feasible and safe for obtaining better outcomes without artificial materials. Although the long-term outcome of this technique is still unclear, we believe that it will contribute to decreasing the particular complications related to laparoscopic Roux-en-Y gastric bypass for morbid obesity.     

Surgical Management of Gastrogastric Fistula After Roux-en-Y Gastric Bypass: 10-Year Experience

Background

Gastrogastric fistula (GGF) occurs in 1–6% of patients who undergo Roux-en-Y gastric bypass (RYGB) for morbid obesity. The pathophysiology may be related to gastric ischemia, fistula, or ulcer.

Objectives

The purposes of the study are to describe the principles of management and to review the literature of this uncommon complication.

Setting

The setting of this study is University Hospital, France.

Materials and Methods

We conducted a retrospective review of all patients’ records with a diagnosis of GGF after RYGB between January 2004 and November 2014.

Results

During the study period, 1273 patients had RYGB for morbid obesity. Fifteen patients presented with a symptomatic GGF (1.18%). The average interval from surgery to presentation was 28 months (22–62). A history of marginal ulcer or anastomotic leak was present in nine patients (60%). The most common presentation was weight regain (80%), followed by pain (73.3%). Two types of fistulas were identified, an exclusively GGF (high) and a gastro-jejuno-gastric fistula (low). High GGF, frequently associated with dilatation of the gastric pouch, was treated by a sleeve of the pouch and sleeve resection of the remnant stomach (nine patients). Low GGF was treated with gastric resection coupled with a revision of the gastrojejunal anastomosis (six patients). All patients were treated laparoscopically with no conversion to laparotomy. The average length of postoperative hospital stay was 5.2 days (range 3–10).

Conclusion

GGF after RYGB is a rare complication. Its pathophysiology remains unclear. Surgical management is the definitive treatment.

     

Laparoscopic inflatable band with Roux-en-Y gastric bypass

Background: Roux-en-Y gastric bypass (RYGBP) leaves a large blind gastric segment, which is inaccessible for conventional endoscopy. Method: A case is reported, describing a variation of laparoscopic RYGBP by partitioning the stomach by an inflatable band rather than by stapling or division. Results:The stomach was partitioned into a proximal 15 cc pouch and a distal part by an adjustable gastric band. A RYGBP was fashioned from the proximal pouch. 9 patients were treated with this technique: 7 as an initial procedure and 2 after previous gastric banding which had been followed by insufficient weight loss. 1 of these latter patients developed erosion of the band through the gastrojejunostomy 7 months postoperatively. Conclusion: Laparoscopic proximal RYGBP with inflatable-band gastric partitioning is feasible. Erosion of the band though the gastrojejunostomy, however, might be a serious side-effect of this technique.     

Laparoscopic remnant gastrectomy: a novel approach to gastrogastric fistula after Roux-en-Y gastric bypass for morbid obesity

BACKGROUND: Gastrogastric fistula (GGF) is a relatively rare and devastating complication after divided Roux-en-Y gastric bypass (RYGB) for morbid obesity. The aim of this study was to review laparoscopic remnant gastrectomy (LRG) as a novel treatment option for this complication. STUDY DESIGN: After IRB approval, we retrospectively reviewed data from all patients who underwent bariatric surgery at Cleveland Clinic Florida and from all patients who were diagnosed with GGF as a complication of RYGB, between January 2000 and March 2005. Data collected included demographics, body weight, symptoms, initial diagnostic method, indications for LRG, and postoperative complications. RESULTS: Of 1,400 patients who had undergone RYGB in our institution during the study period, 21 patients (1.5%) were diagnosed with GGF; 4 more patients who were admitted with GGF after RYGB underwent the initial operation at another institution. Of these, 15 patients underwent LRG. Indications for surgical treatment were intractable epigastric pain (10 of 15), upper gastrointestinal bleeding (2 of 15), intolerance of soft diet (2 of 15), and weight regain (1 of 15). Mean hospital length of stay after the procedure was 4.7 days. There was no mortality, and there was no recurrence of GGF during the followup period. CONCLUSIONS: LRG appears to be a safe and effective surgical procedure for selective patients with GGF after RYGB.     

Laparoscopic Repair of a Staple-line Disruption after an Open Uncut Roux-en-Y Gastric Bypass

The technique of gastric bypass has undergone an evolution over the last 20 years, although it is often individualized based on surgeon preference. Whereas many surgeons divide and separate the gastric pouch from the distal bypassed stomach, some surgeons choose to staple, but not cut and separate the pouch. Staple-line failure resulting in a gastrogastric fistula and weight regain is a worrisome complication. We discuss a case of a patient with an obvious staple-line failure, which resulted in complete weight regain. She underwent laparoscopic repair and was discharged on postoperative day 1. Laparoscopic repair of a staple-line disruption after an open uncut gastric bypass is feasible. Presented at the World Congress of the International Federation for the Surgery of Obesity, Sydney, Australia, August 31, 2006.     

Failure of gastric bypass following several gastrointestinal hemorrhages

Gastrointestinal hemorrhage is an infrequent major complication of gastric bypass. We present a 22-year-old morbidly obese man who underwent a laparoscopic Roux-en-Y gastric bypass and had several life-threatening hemorrhages from both the gastric pouch and gastric remnant, associated with an intra-abdominal hemorrhage. The patient underwent two subsequent reoperations, leading eventually to gastrectomy. The possibility to discover all the sources of bleeding after gastric bypass is discussed, and the adoption of a modification of the procedure that allows the investigation of the excluded stomach is suggested.     

Endoscopic Management of Gastrogastric Fistulae Does Not Increase Complications at Bariatric Revision Surgery

Background  

Gastrogastric fistula (GGF) is a challenging complication of primary obesity surgery that often leads to revision surgery. The impact of prior endoscopic intervention on subsequent surgical revisional outcomes remains unknown. We present the largest series of Roux-en-Y gastric bypass GGF with subsequent surgical revision of fistulae to date.     

Virtual Gastroduodenoscopy: A New Look at the Bypassed Stomach and Duodenum After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: After open or laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity, the bypassed stomach and duodenum are not readily available for radiological and endoscopic evaluation. Furthermore, little is known about the long-term physiologic and histologic changes that occur in the bypassed GI segments following these procedures. Many alternative radiological and endoscopic techniques have been described to access the distal gastric pouch and the duodenum after RYGBP. Apart from percutaneous gastrografin? studies, all these techniques require the insertion of a gastrostomy tube in the distal stomach. Methods: a new diagnostic method to access the bypassed segments by virtual CT gastroscopy (VG) was used in 5 morbidly obese patients who underwent laparoscopic RYGBP (LRYGBP). Results: All patients tolerated the procedure well, which appears safe and suitable for an outpatient setting.The virtual images offered an excellent intraluminal view of the stomach and duodenum. Conclusions: VG holds promise as the method of choice in the follow-up of LRYGB patients, having the potential to detect inflammatory changes and cancer in the excluded segments early.     

Intraoperative Endoscopic Test Resulting in No Postoperative Leaks from the Gastric Pouch and Gastrojejunal Anastomosis in 366 Laparoscopic Roux-en-Y Gastric Bypasses

Background: Postoperative leak from the gastric pouch and the anastomosis are leading causes of morbidity and mortality after gastric bypass. Many modalities have been emerging to prevent this complication. 326 consecutive laparoscopic Roux-en-Y gastric bypasses (LRYGBP) were analyzed in a two-surgeon practice and found no incidence of leaks from the gastric pouch (GP) and the gastrojejunal anastomosis (GJA) with intraoperative endoscopic testing. Methods: 328 consecutive RYGBP performed in antecolic fashion from March 2003 to January 2004 were analyzed. 326 (99%) were performed laparoscopically. After creating a 15 to 25 cc gastric pouch, integrity of the GP and GJA was tested for leak under saline submersion with endoscopic insufflation and placement of a bowel clamp on the intestinal limb distal to the GJA. Suture repair of apparent leak was performed if needed. Results: Of 326 consecutive LRYGBP utilizing the endoscopic leak test, there was no incidence of leak from the GP or GJA. There was one leak from the jejuno-jejunosotmy which was repaired laparoscopically on postoperative day #1. There was no incidence of leaks in the 2 open RYGBPs. Conclusions: Many "leak prophylaxis" measures have been emerging to prevent this potentially devastating complication. However, checking the GP and GJA with a simple endoscopic test can minimize the incidence of leaks after LRYGBP.     

Endoscopic Treatment of Gastrocutaneous Fistula following Gastric Bypass for Obesity

Bariatric surgery, mainly laparoscopic Roux-en-Y gastric bypass, is widely considered to be the best operation for the treatment of morbid obesity. Leak or fistula of the gastrojejunostomy is a feared complication of this procedure. A patient who developed a gastrocutaneous fistula and was successfully managed endoscopically is reported.     

Preoperative upper endoscopy is useful before revisional bariatric surgery.

BACKGROUND AND OBJECTIVES: We hypothesized that patients who have previously had bariatric surgery and are undergoing revision to laparoscopic Roux-en-Y gastric bypass would have abnormal findings detected by upper endoscopy that could potentially influence patient management. The procedures that are being revised include vertical banded gastroplasty, laparoscopic adjustable gastric bands, nonadjustable gastric bands and previous Roux-en-Y gastric bypass (open and laparoscopic). METHODS: We conducted a retrospective chart review of patients who previously had undergone vertical banded gastroplasty or nonadjustable gastric banding. We preoperatively performed an upper endoscopy on all patients. The endoscopy reports were reviewed and the findings entered into a database. RESULTS: Eighty-five percent of 46 patients undergoing revisional bariatric surgery had an abnormal upper endoscopy. Eleven percent had a gastrogastric fistula. Gastritis and esophagitis were noted in 65% and 37%, respectively. Eleven percent of patients had band erosion, 2 from a nonadjustable band, and 5 from vertical banded gastroplasties. Based on our findings, 65% of our patients required medical treatment. CONCLUSIONS: Preoperative upper endoscopy provides valuable information before revisional laparoscopic bariatric surgery. In addition to identifying patients who need preoperative medications, the preoperative upper endoscopy also provided valuable information regarding pouch size and anatomy. Preoperative upper endoscopy should be performed by the operating surgeon on every patient undergoing revisional bariatric surgery.     

Surgery for morbid obesity: 2. Complications. Results of a Technologic Evaluation by the ANAES

The frequency of bariatric surgery has increased markedly in France in recent years, partly due to a better appreciation of the problem of morbid obesity but also due to the commercial introduction of adjustable gastric banding devices which can be placed by laparoscopic approach. Numerous complications of this surgery are known and require recognition to be appropriately treated. Studies of complications suffer from selection bias, methodologic flaws, and lack of follow-up. The incidence and type of complication are affected by the learning curve and surgical techniques. Postoperative mortality varies from 0.14% for laparoscopic gastric banding (LGB), to 0.31% for vertical banded gastroplasty (VBGP) and 0.35% for Roux-en-Y gastric bypass (GBP); pulmonary embolus accounts for 60-70% of deaths in all groups combined. Early post-operative complications vary with specific procedures. Abdominal wall complications, already frequent in an obese population, are decreased from 10% for open procedures to 6% for laparoscopic gastric banding. Both VBGP and GBP are now being done laparoscopically with increasing frequency. Complications specific to LGB include gastric perforation (0.3%), or port problems (5%). Complications with VBGP and GBP include fistula (1-3%), deep abscess, and pulmonary embolus (2%). Global early morbidity is 4.2% for LGB, and varies from 6.4%-22% for VBGP and 6.2%-11.3% for GBP depending on laparoscopic versus open approach. Late mechanical complications are also specific to type of surgery. Pouch dilatation is the most common late complication of LGB (6.3%) and seems related both to operative experience and to site of placement of the band; it has decreased with higher positioning of the band to leave a minimal gastric pouch and with dissection through the pars flaccida of the lesser omentum instead of directly along the muscular wall of the stomach. It usually requires reintervention. Erosion of the gastric band into the stomach (1.6%) is often asymptomatic and is suggested by late weight gain. With VBGP, disruption of a gastric staple line occurs in 12.1% and stenosis of the outlet with proximal dilatation in 6.5%; erosion of the calibrating band of Marlex or silastic occurs in 2.7%. With GBP, the disruption of a staple line across an intact stomach (23%) has become less of a problem with division of the gastric pouch from the distal stomach (2%). Stenosis of the gastrojejunostomy (3.7%) and marginal ulcer (3.5%) are not uncommon. The incidence of wound hernia, obstructive adhesions, and late cholecystectomy vary with the length and thoroughness of follow-up. Late functional complications such as vomiting, dysphagia, heartburn and esophagitis vary with the quality and length of follow-up study. GBP may cause diarrhea and dumping syndrome. Nutritional complications are more common with GPB than with purely restrictive procedures; iron, folate, and Vitamin B12 deficiency are the rule with GBP and require routine replacement therapy; iron deficiency has been noted even with LGB. ate death seems more related to co-morbidities than to the intervention itself. Thorough long-term follow-up study of complications is indispensable for assessment of outcomes and improvement of laparoscopic techniques. Even the less traumatic surgical approach of laparoscopic band placement should not be considered free of risk; strict adherence to pre-operative surgical indications should be maintained.     

Gastro-gastric Fistula between Pouch and Fundus following Gastric Banding and Bypass

A complication observed with revisional surgery involving a fistula between the former pouch after gastric banding and the fundus is described. A 59-yearold man with BMI 41 kg/m² presented for Roux-en-Y gastric bypass (RYGBP). He had previously undergone an open gastric banding operation, with the band removed for obstruction 1 year later. He presented to our hospital with a third incisional hernia which was so large that he suffered from abdominal angina following meals. A RYGBP and a hernia repair with mesh were performed. The postoperative contrast xray study disclosed a fistula between the pouch and fundus. A procedure to close the fistula became necessary. The reason for the fistula may have been an erosion at the former connection between the pouch and the fundus after gastric banding, although a preoperative gastroscopy had not revealed this fistula.     

Incidental Finding of Gastrointestinal Stromal Tumors (GISTs) during Laparoscopic Gastric Bypass

Background: Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for <1% of all neoplasms of the alimentary tract. GISTs have not been previously reported in association with gastric bypass surgery. Methods: This study is a retrospective review of 517 consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) between January 2002 and August 2005. Incidental intraoperative findings of gastric GIST were recorded. Results: 4 patients (0.8%) were noted to have GISTs intra-operatively upon inspection of the stomach prior to partition. All GISTs were identified along the anterior aspect of the upper third of the stomach and were removed by laparoscopic wedge excision with at least a 1 cm margin. The 4 tumors were <1 cm in size and all had immunohistochemical analysis positive for CD117 (c-kit). None of the tumors had determinants of malignant behavior (high mitotic rate, necrosis or pleomorphism). Conclusion: We have found a 0.8% incidence of gastric GISTs in our morbidly obese patients undergoing LRYGBP. All of these small, benign tumors were found incidentally in asymptomatic patients. This case series underscores the need to fully assess the stomach prior to gastric pouch formation. Without the ability to grossly determine the benign or malignant behavior of GISTs, all these tumors found incidentally should be resected with adequate margins.     

Laparoscopic gastric bypass complicated by gastric pouch necrosis: considerations in gastroesophageal reconstruction

Gastric pouch necrosis and intraabdominal sepsis is an uncommon complication following laparoscopic gastric bypass. The intraoperative management of this complication centers on resection of the necrotic pouch, esophageal diversion, drainage, and enteral access for nutrition. Reestablishing gastrointestinal continuity at a later surgery following this complication can be challenging. We present a case in which the colon was found to be unacceptable for use in reconstruction; the remaining stomach was used as the conduit for a transhiatal reconstruction of gastrointestinal continuity instead.     

Gastrocutaneous fistula: etiology and treatment

Gastrocutaneous fistula is an infrequent but serious surgical complication which has received little attention in the recent literature. The current report analyzes 13 patients with this complication. The fistula most commonly occurs in the fundic portion of the greater curvature of the stomach and is usually a result of unrecognized iatrogenic injury or associated with severe left upper quadrant inflammation and external drainage. Clinical recognition occurs when the patient develops left subphrenic sepsis or drains gastric content. The fistula is best documented by upper gastrointestinal contrast studies and usually responds to wide drainage and supportive treatment in the presence of benign disease. Oral alimentation apparently need not be delayed until complete fistula closure.     

Laparoscopic Roux-en-Y Gastric Bypass with 2-metre Long Biliopancreatic Limb for Morbid Obesity: Technique and Experience with the First 150 Patients

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity. We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m long biliopancreatic limb (BP-limb). Methods: Between November 2001 and November 2003, a prospective analysis of 150 patients was performed identifying technical success and complications. Before surgery, patients underwent a strict multidisciplinary behavioral program. At operation the stomach was transected proximally with a linear stapler (60-mm, Endo-GIA) to create a prolongation of the esophagus (gastric tube) along the lesser curvature, resulting in a 40-50 ml pouch. Two meters of the proximal jejunum were bypassed (BP-limb), creating an antecolic Roux-en-Y gastro-jejunostomy to the posterior wall of the gastric tube using a 45-mm linear Endo-GIA stapler. The entero-anastomosis was created 50 cm below the gastro-jejunostomy, also with a 45-mm linear Endo-GIA. Results: Mean BMI was 50.0, and 78% of patients were females. With 100% follow-up, we found an EWL of 50% 6 months after surgery, gradually rising to 80% after 18 months. The mean operating time was 116 min for the first 50 cases and decreased to 82 min for the last 50 cases. Intestinal leakage occurred in 5 patients (3%) and bleeding in 5 (3%). Most of these complications occurred in the first 50 cases, and all but one were treated successfully with an early laparoscopic re-operation. Marginal ulcers were found in 16.6% of patients. No internal hernias have occurred. Conclusion: The operation demands advanced laparoscopic skills, but technically it is relatively simple and has an acceptable complication rate. Short-term results regarding excess weight loss are at least comparable to the RYGBP with a long alimentary limb.     

Laparoscopic Roux-en-Y gastric bypass with linear cutter technique: comparison of four-row versus six-row cartridge in creation of anastomosis.

BACKGROUND: Morbid obesity is refractory to medical treatment. The introduction of laparoscopic linear staplers in the early 1990s contributed to the development of the laparoscopic Roux-en-Y gastric bypass technique. Many series have compared different brands of circular and linear staplers. The purpose of this study was to evaluate the 4-row versus 6-row endoscopic staplers in laparoscopic Roux-en-Y gastric bypass for creation of the anastomosis. METHODS: Between July 2000 and April 2004, 1240 patients underwent laparoscopic Roux-en-Y gastric bypass. The 4-row linear stapler was used in the first 664 cases (group 1) and the 6-row stapler in the latter 576 patients (group 2) to create the anastomosis. The medical records of those patients who developed leaks, gastrogastric fistulas, strictures, or bleeding were reviewed. Strictures were diagnosed using radiologic or endoscopic techniques. RESULTS: Leaks were more frequent in group 2 than in group 1 (1.56% versus 1.05%, respectively, P = .46). Documented bleeding occurred in 15 and 13 patients in groups 1 and 2, respectively (2.26% for both). Strictures were diagnosed in 7.68% of patients in group 1 (51 gastrojejunostomy and 4 jejunojejunostomy), and in 4.3% of those in group 2 (25 gastrojejunostomy stenosis, P = .017). Gastrogastric fistulas were found in 5 patients (.75%) in group 1 and 6 (1.04%) in group 2. CONCLUSION: Using a 6-row instead of a 4-row linear cutter technique to create the anastomosis yielded similar results, but the stricture rate at the gastrojejunal anastomosis was significantly lower with the newer, 6-row staplers.