MANAGEMENT OF LARGE GASTROGASTRIC FISTULA FOLLOWING ROUX-EN-Y GASTRIC BYPASS: COMPARISON OF ENDOSCOPIC CONVERSION TO SLEEVE GASTROPLASTY VERSUS SURGICAL REVISION
Pichamol Jirapinyo*, Ethan D. Maahs, Christopher C. Thompson
Brigham & Women's Hospital, Boston, MA
Introduction: Gastrogastric fistula (GGF) is a known complication of Roux-en-Y gastric bypass (RYGB) that may contribute to weight regain. Surgical revision may be technically challenging, while endoscopic closure especially of large GGF has limited efficacy. Endoscopic remodeling of the remnant stomach has been proposed as a potential solution to this problem.
Aim: (1) To assess technical success, safety and 12-month efficacy of a sleeve through fistula (STF) procedure in the treatment of weight regain in GGF. (2) To compare outcomes of STF to traditional surgical revision of GGF.
Methods: This study was a retrospective review of prospectively collected data on RYGB patients with large GGF (≥10 mm) who underwent STF. Patients with GGF who had marginal ulceration, reflux or diabetes recurrence were not offered STF. STF: Remnant stomachs were accessed through GGF and were reduced in volume via endoscopic sleeve gastroplasty (ESG) or gastric plication (GP) (Figure 1). Part 1: Technical success rate, serious adverse event (SAE) rate and percentage total weight loss (TWL) at 6 and 12 months following STF. Part 2: Comparison of outcomes to those of traditional surgical revision of GGF.
Results: Part 1: 23 RYGB patients with GGF underwent STF (9 ESG and 14 GP) (Table 1). Symptoms included weight regain (100%) and abdominal discomfort (43%). GGF size was 18.6±5.9 mm. Part 1: Technical success rate was 100%. A median of 4 sutures with 34 [19-61] stitches (bites) or 14 [8-21] plications were placed per sleeve. Additionally, outlet reduction/closure was performed to divert nutrients into the remnant sleeve in 17/23 (74%). SAE occurred in 2/23 patients (9%) including post-operative fevers that resolved with antibiotics and GI bleeding that required no intervention or transfusion. At 6 and 12 months, patients lost 8.1±6.5 kg and 8.2±10.9 kg (p<0.0001 and 0.03), corresponding to 7.1±4.9% and 6.5±7.5% TWL, respectively. There was no difference in amount of weight loss between those who underwent STF via ESG or GP. Part 2: STF was associated with similar weight loss compared to surgical revision at 6 months. However, at 12 months, surgical patients experienced greater weight loss. The proportion of patients who achieved clinically significant weight loss (≥5% TWL) was similar between groups (64% in STF vs 80% in surgical groups, p=0.25). The SAE rate was higher in the surgical group compared to the STF group (p=0.002) (Table 1). 16% (11/68) of surgical group had persistence or recurrence of GGF.
Conclusion: Endoscopic remodeling of the remnant stomach appears effective in treating weight regain due to large GGF, with a similar overall response rate to surgical revision. Weight loss is significantly greater with surgical revision, however, the SAE rate is also significantly higher. Longer term data is needed to better guide therapy.
Figure 1. A sleeve through fistula procedure using (A) an endoscopic suturing device to remodel the remnant stomach via an endoscopic sleeve gastroplasty (ESG) suture pattern (B) an endoscopic plication device to remodel the remnant stomach via a circumferential and longitudinal plication pattern. Three arrows represent large gastrogastric fistulae. One arrow represents gastrojejunal anastomoses.
Table 1. Characteristics and outcomes of RYGB patients with large gastrogastic fistula who underwent a sleeve through fistula procedure or surgical revision for gastrogastric fistula.
Back to 2020 Abstracts