Laparoscopic Handsewn Gastrojejunostomy Revision of Gastrojejunal Anastomosis with Takedown of Gastro-gastric Fistula

Background Marginal ulcer (MU) and gastro-gastric fistula (GGF) are well-described complications following Roux-en-Y gastric bypass (RYGB). The incidence of MU ranges from 0.6 to 25% and the incidence of GGF following divided RYGB has been reported as high as 6%. MU has been shown to be associated with GGF with a 53% incidence of MU in patients with GGF versus 4% in patients without GGF. Other risk factors for developing GGF previously identified in the literature include incomplete gastric transection, staple-line leak, and foreign body erosion. Management of GGF begins with aggressive medical therapy aimed at decreasing acid production, and surgical intervention is indicated for persistent symptoms such as weight gain or persistent ulcers. Endoscopic therapy is not recommended given risk of failure in setting of chronic inflammation. Methods To demonstrate the operative management of gastro-gastric fistula from chronic marginal ulcer. A 52-year-old female who had previous robotic RYGB in 2012 developed a chronic marginal ulcer and was diagnosed with a gastro-gastric fistula in 2017. She had a suspected perforation of her marginal ulcer in 2018, although no ulcer was found on laparoscopic exploration. She was taken to the OR for revision in 2018 for chronic marginal ulcer and strictures. Two gastro-gastric fistulas were found and resected, and a redo gastrojejunostomy was performed. Results We used a handsewn RYGB technique in this patient, and other options include circular or linear techniques to create the gastrojejunal anastomosis [GJA]. We have found the rate of both stricture and marginal ulcer higher after circular stapled GJA technique. She did well post-operatively and did not have any further issues with marginal ulcers or strictures. Conclusions A significant number of patients with GGF will fail maximal medical therapy and will require surgical treatment. Laparoscopic resection of GGF is the most well-described surgical technique, with or without revision of the gastrojejunostomy depending on presence of anastomotic stricture, marginal ulcer, or involvement with GG fistula. Surgical therapy has been shown to lead to good outcomes.