Gastro-gastric fistula is a late complication that can occur after Roux-en-Y gastric bypass even after complete gastric division (isolation) during construction of the gastric pouch. The incidence of this complication varies depending on whether the gastric pouch is isolated (0-3%) or non-isolated (29%). We present a feasible technique for laparoscopic gastro-gastric fistula repair using endoscopic assistance.

The patient is a 36 year-old morbidly obese woman with a body mass index of 44 kg/m² who under went Roux-en-Y gastric bypass laparoscopically just over 1 year ago. She had good initial weight loss but began regaining after 6 months. An upper GI demonstrated a gastro-gastric fistula without filling of the Roux limb. An upper endoscopy confirmed a one cm fistula opening.

We decided to undertake laparoscopic repair. Multiple adhesions were immediately encountered involving the gastric pouch and gastric remnant, suggesting the possibility of a sub-clinical leak associated with her previous operation. The short gastric vessels along the greater curvature of the gastric remnant were taken to better expose the Roux limb, which was in a retrocolic retrogastric position. Dissection was made toward the fistula until dense adhesions obscure the tissue planes. At this point an endoscope was placed trans-orally to assist in precisely locating the fistula and guide further dissection. The fistula opening was seen endoscopically with an associated staple. The gastric remnant was then intubated through the fistula.

Palpation with laparoscopic instruments helped identify the location of the fistula relative to the endoscope. Dissection was then carried down onto the endoscope at the location of the fistula. Further manipulation of the endoscope and dissection opens the fistula, after which the endoscope is used for retraction. The proximal gastric remnant was dissected free and excised and the staple line over-sewn. Prior to fistula closure the endoscope was advanced through the stoma into the Roux limb to avoid narrowing the anastomosis during this maneuver. A linear stapler was used for fistula closure and the staple line over-sewn. We always use 4.8 mm green cartridge staple loads and we over-sew all staple lines during re-operative procedures. As is our routine, a leak test was performed under saline emersion and the anastomosis inspected endoscopically to ensure that no narrowing of the anastomosis has occurred. A drain is placed as is our routine for all bariatric re-operations.

The patient was discharged on post-operative day four and on clinic follow-up at one month was doing well and beginning to lose weight.

This video addresses the appearance of a gastro-gastric fistula after Roux-en-Y gastric bypass and demonstrates a technique for repair that combines laparoscopic and endoscopic approaches.