Gastrogastric fistulas. A complication of divided gastric bypass surgery

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

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.

Treatment of gastrogastric fistula after Roux-en-Y gastric bypass: surgery combined with gastroscopy

A 53-year-old male who had previously undergone an open gastric bypass (Capella-Fobi) developed a gastrogastric fistula during the late postoperative course. Because he regained weight and had a stomal ulcer difficult to control, it was decided to submit him to revisional surgery. At laparotomy, a retrogastric approach plus gastroscopy permitted easy identification and closure of the fistula. The patient is doing well and losing weight after this reoperation.

Use of bioabsorbable staple reinforcement material in gastric bypass: a prospective randomized clinical trial

BACKGROUND

Staple line failure, although uncommon, can result in significant morbidity and, even, mortality. Staple line buttressing has been developed to improve staple line strength, decrease bleeding, and minimize the risk of leak. Many different products are currently available. However, most have not been proved in clinical trials for their clinical relevance.

METHODS

From April 2004 to March 2005, 48 morbidly obese patients who had undergone laparoscopic Roux-en-Y gastric bypass were enrolled in this study. The patients were randomly allocated to 2 groups according to whether polyglycolide acid and trimethylene carbonate (Seamguard) was (group 1, n = 24) or was not (group 2, n = 24) used in an investigator-initiated study. All patients underwent barium radiography at 3 and 12 months postoperatively.

RESULTS

Peri- and postoperative mortality were absent. The intraoperative methylene blue test was positive in 1 patient in group 2. No conversion to laparotomy was needed. No patient required reoperation or transfusion for extraluminal bleeding, and no anastomotic leaks were detected in either group postoperatively. The mean number of clip instruments used was significantly lower in group 1 patients (2 versus 22, P <.0001, odds ratio 121.0, 95% confidence interval 12.5-1491). The operative time was significantly less in group 1 (115 +/- 30.0 min, range 85-210) compared with that in group 2 (150 +/- 51.7 min, range 90-240; P <.05). The postoperative hemoglobin level was significantly greater in group 1 (12.47 +/- 1.7 mg/dL, range 9.2-14.8) compared with that in group 2 (11.1 +/- 1.9 mg/dL, range 8.1-14.6; P <.05). Gastrogastric fistula formation was detected in 3 patients (12.5%) in group 2, with no statistically significant difference (P = .2).

CONCLUSION

The results of our study have shown that synthetic reinforcement material minimizes staple line bleeding and reduces the operative time, with no animal source contamination. No adverse events related to the resorbable buttressing material were observed.

Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients

BACKGROUND

Marginal ulceration after Roux-en-Y gastric bypass (RYGB) is diagnosed in 1% to 16% of patients. The factors predisposing patients to marginal ulceration are still unclear.

METHODS

A total of 260 patients who underwent laparoscopic RYGB were retrospectively reviewed. Data regarding demographics, comorbidities, body mass index (BMI), Helicobacter pylori infection, gastrojejunal (GJ) anastomotic leaks, postoperative bleeding, operative time, type of suture material, and marginal ulcer formation were collected. Fisher's exact test was used for statistical analysis of discrete variables, and Student's t-test was used for continuous variables. Statistical significance was set at an alpha of 0.05.

RESULTS

The overall marginal ulceration rate was 7%. Demographic data (age, gender distribution, BMI) did not differ significantly between patients who experienced marginal ulceration and those who did not (p > 0.05). Similarly, technical factors (choice of permanent or absorbable suture for the GJ anastomosis, attending as primary surgeon, robotic GJ, operative time, postoperative hematocrit drop) were not statistically different between the two groups (p > 0.05). Finally, the prevalence of comorbidities (diabetes, hypertension, obstructive sleep apnea, musculoskeletal complaints, dyslipidemia, gastroesophageal reflux disease [GERD] and peptic ulcer disease [PUD]) did not differ significantly between the two groups (p > 0.05). However, preoperative H. pylori infection, although adequately treated, was twice as common among the patients who had marginal ulceration (32%) as among those who did not (12%) (p = 0.02). All the patients who experienced marginal ulcers had complete resolution of symptoms with proton pump inhibitors and sucralfate. No reoperations were required for marginal ulceration.

CONCLUSION

Helicobacter pylori may potentiate marginal ulcer formation. The authors hypothesize that H. pylori damages the mucosal barrier in a way that persists postoperatively, which may precipitate marginal ulceration even when the organism has been medically eradicated.

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.

Nutrition and gastrointestinal complications of bariatric surgery

At present, bariatric surgery is the only treatment that can achieve meaningful and sustainable weight loss for the millions of morbidly obese individuals. The current popular operative procedures (the Roux-en-y gastric bypass, laparoscopic adjustable gastric band, and the biliopancreatic diversion with or without duodenal switch) are all relatively safe and effective. However, all of these procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract. This fact, along with postoperative dietary changes, makes these patients vulnerable to a multitude of potential complications. As more and more patients undergo these procedures, an increasing number of clinicians will be asked to care for them. It is therefore imperative that all clinicians have a general understanding of the operative procedures and the potential problems these patients may develop. This article will describe these operative procedures and will discuss the more common consequences.

A New Approach for Treatment of Gastro-Gastric Fistula after Gastric Bypass

We report a novel technique for gastro-gastric fistula (GGF) repair. A 44-year-old woman was found to have a fistula between her gastric pouch and bypassed stomach 18 years after Roux-en-Y gastric bypass (RYGBP) for morbid obesity. She underwent an attempted open surgical repair, which was complicated by postoperative abdominal sepsis. An upper gastrointestinal series, abdominal CT scan and upper endoscopy confirmed the diagnosis of failed surgery with recurrent GGF. Under endoscopic and fluoroscopic guidance, two ports were inserted percutaneously into the stomach. The fistula was closed with a percutaneous, transgastric, totally extraperitoneal approach. She remains well 7 months after this intervention. This procedure appears to be a safe and effective minimally invasive approach for closure of GGF after RYGBP. This is the first description of an intragastric, percutaneous closure of a GGF after RYGBP in the medical literature. Further experience with this technique is needed to define the selection criteria, limitations, advantages, and disadvantages.

Staple line reinforcement with new biomaterial increased burst strength pressure: an animal study

BACKGROUND

Most bariatric operations rely on stapler devices. Although today staplers are extremely safe, efficient, and reliable, a potential risk exists for staple line failures, leading to three complications: leaks, fistulas, and bleeding. Porcine small intestinal submucosa strip applied over the staple line suture might help prevent these problems.

METHODS

Forty animals (canine model developed at the University of São Paulo, São Paulo, Brazil) underwent general anesthesia and laparotomy. One nonreinforced staple line suture and one staple line suture reinforced with Surgisis SLR was created in each animal. The burst strength pressure of the 80 staple line sutures was obtained. Suture line bleeding and the ease of use of the membrane were also noted. The data were compared (Student's t test). The dogs were euthanized after the procedure. Two surgeons with experience in stapler devices performed all procedures.

RESULTS

The mean +/- SD burst pressure was 209.26 +/- 76.41 mm Hg and 441.33 +/- 128.64 mm Hg for the stapler line without and with the biodegradable membrane, respectively. The difference was statistically significant (P = .002). No in vivo suture line bleeding occurred. The biodegradable membrane was easy to use.

CONCLUSION

The biodegradable membrane was able to increase the burst strength pressure of the bowel segment staple line. It might help prevent some causes of staple line leaks.

Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass

BACKGROUND

Gastrogastric fistula is a communication between the proximal gastric pouch and the distal gastric remnant, rarely described in the realm of bariatric procedures. The aim of this study was to review the existing literature about this topic and to demonstrate its laparoscopic treatment.

METHODS

An extensive literature review found several articles reporting this complication. However, no citation was found describing the steps of the laparoscopic management of this situation.

RESULTS

Gastrogastric fistula occurs in up to 6% of Roux-en-Y gastric bypasses. Two theories exist for fistula formation: (1) it is a technical complication derived from the incomplete division of the stomach during the creation of the pouch, and (2) it occurs after a staple-line failure, developing a leak with an abscess, which then drains into the distal stomach forming the fistula. Early symptoms include fever, tachycardia, and abdominal pain. Failure in weight loss is a late clinical sign observed in these patients. Diagnosis is based on radiologic study, upper endoscopy and computed tomography. When identified in the acute postoperative course, laparoscopic treatment is easy. Chronic fistulas are difficult to manage, and the laparoscopic approach is an alternative to open surgery.

CONCLUSIONS

Gastrogastric fistula is a possible complication of Roux-en-Y gastric bypass and its laparoscopic treatment is feasible.

Complications of bariatric surgery

The rise in bariatric operations has been exponential because of the greater acceptance for these procedures. Although complication rates are relatively low, they can result in formidable disability. Adverse outcomes also result in medical malpractice claims that are particularly problematic for bariatric surgery practices. For these reasons, surgeons performing these operations must be knowledgeable and must possess the technical skills required for managing complications when they occur. The purpose of this article is to review the major complications that occur following anti-obesity procedures and to provide recommendations regarding their management.

Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure.

METHODS

We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery.

RESULTS

The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically.

CONCLUSION

Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.

Results of gastric bypass plus resection of the distal excluded gastric segment in patients with morbid obesity

Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.

Management of the bariatric surgery patient

Morbid obesity has reached epidemic proportions in the United States. Unfortunately, medical interventions have been largely ineffective in this growing population. Currently bariatric surgery is the most effective intervention in managing morbid obesity and its comorbidities. As more patients become eligible for and pursue weight reduction surgery, it becomes important for the clinician to possess a thorough understanding of the different procedures available and the management of patients before, during, and after these surgeries. Significant weight loss and improvement in weight-related comorbidities are possible, with the best results available to the well-informed patient whose care is provided by a dedicated multidisciplinary team.

Gastric bypass

Nearly all morbidly obese patients with satisfactory postoperative weight loss experience substantial improvement in the quality of their lives. Improved health status is characterized by increased exercise tolerance and improvement or resolution of obesity-related comorbidities. Improvement of obesity-related medical problems (discussed in the article by Klein elsewhere in this issue) is a primary goal of gastric bypass. The patient's ability to interact with others in social situations is also enhanced. At present, RYGB may be the only bariatric operation that has produced durable long-term weight loss at an acceptable level of risk.

Resectional gastric bypass is a new alternative in morbid obesity

BACKGROUND

Severe obesity is a common serious health problem in the United States. Medical therapy is often ineffective. A variety of surgical procedures have been employed for treatment of morbid obesity. Surgical therapy continues to evolve.

METHODS

Eighty-five patients have undergone subtotal gastrectomy and retrocolic Roux-en-Y gastrojejunostomy for weight control at our institution. We refer to this procedure as resectional gastric bypass (RGB). Thirty-eight patients have undergone RGB as conversion from failed or problematic prior bariatric procedures. Forty-seven patients have had RGB as their primary bariatric procedure.

RESULTS

Twenty-six patients undergoing RGB for conversion of an anatomically or functionally failed prior bariatric procedure have had mean additional weight loss of 37% excess body weight (EBWL) in 18 months follow-up. Twelve patients undergoing RGB for intractable side effects of prior bariatric procedures have all had clinical improvement. Forty-seven patients undergoing RGB as a primary procedure have had EBWL of 53%, in mean follow-up of 11 months. For the entire series, major complications were one anastomotic leak, one reexploration for suspected subphrenic abscess, and one major pulmonary embolus. These patients recovered. There was no mortality in the series.

CONCLUSIONS

Resectional gastric bypass is a new alternative for salvage of a failed or problematic prior bariatric procedure. It is also effective as a primary weight control operation.

Nonsurgical factors that influence the outcome of bariatric surgery: a review

OBJECTIVE

Severe obesity (ie, at least 100% overweight or body mass index > or =40 kg/m2) is associated with significant morbidity and increased mortality. It is apparently becoming more common in this country. Conventional weight-loss treatments are usually ineffective for severe obesity and bariatric surgery is recommended as a treatment option. However, longitudinal data on the long-term outcome of bariatric surgery are sparse. Available data indicate that the outcome of bariatric surgery, although usually favorable in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. The objective of this study is to present a review of the outcome of bariatric surgery in three areas: weight loss and improvement in health status, changes in eating behavior, and psychosocial adjustment. The study will also review how eating behavior, energy metabolism, and psychosocial functioning may affect the outcome of bariatric surgery. Suggestions for additional research in these areas are made.

METHOD

Literature review.

RESULTS

On average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty. In about 30% of patients, weight regain occurs at 18 months to 2 years after surgery. Binge eating behavior, which is common among the morbidly obese, may recur after surgery and is associated with weight regain. Energy metabolism may affect the outcome of bariatric surgery, but it has not been systematically studied in this population. Presurgery psychosocial functioning does not seem to affect the outcome of surgery, and psychosocial outcome is generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and suicide.

CONCLUSIONS

Factors leading to poor outcome of bariatric surgery, such as binge eating and lowered energy metabolism, should be studied to improve patient selection and outcome. Long-term outcome data on psychosocial functioning are lacking. Longitudinal studies to examine the long-term outcome of bariatric surgery and the prognostic indicators are needed.

Stomal ulcer after gastric bypass

BACKGROUND

Stomal ulcer is a serious complication of gastrogastric fistula following Roux-en-Y gastric bypass for obesity.

STUDY DESIGN

A 1-8 year continuous followup of 499 patients with gastric bypass in continuity (GB) and isolated gastric bypass (IGB) documented the incidence of fistula formation, development of stomal ulcer, stimulation of acid production within the gastric pouch, and response to treatment.

RESULTS

In 123 GB patients, staple line disruption occurred in 36 (29%) and stomal ulcer occurred in 20 (16%). Gastrogastric fistula with stomal ulcer was significantly lower in 376 patients who underwent IGB, (ie, 11 patients [3%]). Significantly larger amounts of acid, a lower pH, and a greater time with a pH less than 2 were found in the gastric pouches of patients who developed stomal ulcer after Roux-en-Y gastric bypass. All patients had a perforated staple line. Successful closure of the staple line significantly decreased acid production and pH in the gastric pouch when tested before and after remedial operation with healing of stomal ulcers.

CONCLUSIONS

Stomal ulcer after gastric bypass is the result of acid production in the bypassed stomach in the presence of a gastrogastric fistula. Separation of the gastric pouch from the main stomach decreases the incidence of fistula formation and stomal ulcer but does not eliminate it. Interposition of a well vascularized organ, the jejunum between the pouch and main stomach, is an attractive solution for patients who require remedial operations on the stomach and possibly for primary operations as well.

The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus

Of 232 morbidly obese patients with non-insulin-dependent diabetes mellitus referred to East Carolina University between March 5, 1979, and January 1, 1994, 154 had a Roux-en-Y gastric bypass operation and 78 did not undergo surgery because of personal preference or their insurance company"s refusal to pay for the procedure. The surgical and the nonoperative (control) groups were comparable in terms of age, weight, body mass index, sex, and percentage with hypertension. The two groups were compared retrospectively to determine differences in survival and the need for medical management of their diabetes. Mean length of follow-up was 9 years in the surgical group and 6.2 years in the control group. The mean glucose levels in the surgical group fell from 187 mg/dl preoperatively and remained less than 140 mg/dl for up to 10 years of follow-up. The percentage of control subjects being treated with oral hypoglycemics or insulin increased from 56.4% at initial contact to 87.5% at last contact (P = 0.0003), whereas the percentage of surgical patients requiring medical management fell from 31.8% preoperatively to 8.6% at last contact (P = 0.0001). The mortality rate in the control group was 28% compared to 9% in the surgical group (including perioperative deaths). For every year of follow-up, patients in the control group had a 4.5% chance of dying vs. a 1.0% chance for those in the surgical group. The improvement in the mortality rate in the surgical group was primarily due to a decrease in the number of cardiovascular deaths.