Laparoscopic Treatment of Gastro-Gastric Fistula After RYGB: Technical Points.

PURPOSE: Postoperative abdominal pain after Roux en Y gastric bypass associated with gastro esophageal reflux is difficult to manage. A gastro-gastric fistula can be the etiology and besides pain and weight regain, it can also be revealed by a dilatation of the excluded stomach and duodenum.

METHODS: We present the case of a 45-year-old woman who had a medical history of revisional RYGB after failure of gastric band. She recently complained of recurrent epigastric abdominal pain and biliary GERD. Upper gastro intestinal endoscopy found biliary reflux gastritis. The CT scan with gas expansion and opacification revealed a dilated excluded stomach and duodenum leading to the diagnosis of gastro-gastric fistula. Because of pain and GERD correlated to this radiological finding, we decided to perform an exploratory laparoscopy. The patient was placed in a half-sitting position, surgeon between the legs. A 12-mmHg pneumoperitoneum was made. A 4-port technique was used. The first step consisted of a complete adhesiolysis. The second step consisted in the dissection of the excluded stomach, stuck to the gastric pouch, and revealed two gastro-gastric fistulas treated by stapling. An epiploplasty was performed on the excluded stomach and the staple line of the gastric pouch was invaginated.

RESULTS: Postoperative course was uneventful. One year later, she had no more reflux and no more pain.

CONCLUSION: Causes of abdominal pain and GERD after RYGB are difficult to identify. Gastro-gastric fistula is one of them and should be evoked when biliary reflux and abdominal pain appear.