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MANAGEMENT OF GASTROGASTRIC FISTULA AS A SEQUELA OF MARGINAL ULCER: SURGICAL STRATEGIES AND OUTCOMES
Agustina A. Pontecorvo
*, Tamar Tsenteradze, Enrique F. Elli
Mayo Clinic Florida, Jacksonville, FL
Aims: Gastrogastric fistula (GGF) is a rare complication following Roux-en-Y gastric bypass (RYGB). Various causative factors, including marginal ulcer (MU), can predispose to GGF development. Currently, no studies address surgical management of GGF after MU diagnosis. The objective of our study is to summarize our experience in managing GGF following marginal ulcer diagnosis.
Material and Methods: A retrospective analysis of patients who underwent Revisional Bariatric Surgery (RBS) after RYGB for GGF resolution at our institution was performed between January 1st, 2016, and August 31st, 2024. Patients' demographics were collected, and peri- and postoperative outcomes were evaluated, including weight loss, complications, reinterventions, and MU recurrence.
Results: A total of 20 patients underwent RBS for resolution of GGF, with 13 (65%) treated under a robotic-assisted approach. The mean age at the time of revision was 62.2 years (+ 9.8), and 90% were female. The mean body mass index (BMI) at revision was 32.9 kg/m2 (+ 6.5). Twelve (60%) patients also underwent gastrojejunostomy revision (GJ). Upper GI endoscopy was performed before surgery, demonstrating that the most common ulcer location was at the gastric pouch in 55% of the cases, 30% at the gastrojejunal anastomosis and 15% at the jejunal side of the anastomosis. The mean size of the fistula was 16.3 mm + 9.0. The 30-day readmission and reintervention rates were 25 and 20%, respectively. MU recurrence following RBS was 27.3%. There were no significant differences in postoperative outcomes between the Redo-GJ group and the No-Redo-GJ group. Two subgroups of patients according to their BMI before RBS were identified, 9 patients with BMI < 30 kg/m2 (mean BMI 27.2 kg/m2), and 11 patients with a BMI > 30 kg/m2 (mean BMI 37.6 kg/m2). There was a significant difference in weight and BMI between the two groups in the 1- and 6-month follow up (p<0.001). At the 12-month follow-up, the mean weight for BMI < 30 group was 72.2 kg (+17.9) and 93.5 kg (+4.9) for the BMI > 30 group (p=0.032). In the group with BMI >30, weight decreased during the first-year post-surgery. In contrast, the group with BMI <30 experienced less pronounced weight loss initially, with a slight increase in mean weight and BMI by the 12-month follow-up.
Conclusions: Given the high recurrence rate associated with medical and endoscopic treatments, minimally invasive surgical resolution is a feasible option to address GGF. This complication can cause insufficient weight loss or regain, and when it develops as a sequela of MU, GJ stenosis may also occur, leading to PO intolerance and weight loss. Therefore, an exhaustive preoperative assessment is essential to investigate all potential sequela associated with MU.
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