Journal of Gastrointestinal Surgery

, Volume 11, Issue 12, pp 1673–1679 | Cite as

Surgical Management of Gastro–Gastric Fistula After Divided Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

  • O. N. Tucker
  • S. Szomstein
  • R. J. Rosenthal



Gastro–gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial.


A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006.


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.


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.


Complications Roux-en-Y gastric bypass Morbid obesity Fistula Remnant gastrectomy 



antecolic antegastric


body mass index


computed tomography




gastrograffin upper gastrointestinal study


gastro–gastric fistula




laparoscopic remnant gastrectomy


laparoscopic Roux-en-Y gastric bypass


postoperative day


proton pump inhibitor


remnant gastrectomy


retrocolic retrogastric


Roux-en-Y gastric bypass


  1. 1.
    Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ, Livingston EH, Nguyen NT, Li Z, Mojica WA, Hilton L, Rhodes S, Morton SC, Shekelle PG. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005;142(7):547–559.PubMedGoogle Scholar
  2. 2.
    DeMaria EJ, Jamal MK. Surgical options for obesity. Gastroenterol Clin North Am 2005;34(1):127–142.PubMedCrossRefGoogle Scholar
  3. 3.
    Rosenthal RJ, Szomstein S, Kennedy CI, Soto FC, Zundel N. Laparoscopic surgery for morbid obesity: 1,001 consecutive Bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. Obes Surg 2006;16(2):119–124.PubMedCrossRefGoogle Scholar
  4. 4.
    Cottam DR, Nguyen NT, Eid GM, Schauer PR. The impact of laparoscopy on Bariatric surgery. Surg Endosc 2005;19(5):621–627.PubMedCrossRefGoogle Scholar
  5. 5.
    Nguyen NT, Silver M, Robinson M, Needleman B, Hartley G, Cooney R, Catalano R, Dostal J, Sama D, Blankenship J, Burg K, Stemmer E, Wilson SE. Result of a national audit of Bariatric surgery performed at academic centers: a 2004 University HealthSystem Consortium Benchmarking Project. Arch Surg 2006;141(5):445–449.PubMedCrossRefGoogle Scholar
  6. 6.
    Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y-500 patients: technique and results, with 3–60 month follow-up. Obes Surg 2000;10(3):233–239.PubMedCrossRefGoogle Scholar
  7. 7.
    Gomez CA. Gastroplasty in morbid obesity. Surg Clin North Am 1979;59(6):1113–1120.PubMedGoogle Scholar
  8. 8.
    Mason EE. Vertical banded gastroplasty for obesity. Arch Surg 1982;117(5):701–706.PubMedGoogle Scholar
  9. 9.
    Mason EE, Doherty C, Cullen JJ, Scott D, Rodriguez EM, Maher JW. Vertical gastroplasty: evolution of vertical banded gastroplasty. World J Surg 1998;22(9):919–924.PubMedCrossRefGoogle Scholar
  10. 10.
    Capella JF, Capella RF. Gastro–gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 1999;9(1):22–27.PubMedCrossRefGoogle Scholar
  11. 11.
    Fobi MA, Lee H, Igwe D, Jr, Stanczyk M, Tambi JN. Prospective comparative evaluation of stapled versus transected silastic ring gastric bypass: 6-year follow-up. Obes Surg 2001;11(1):18–24.PubMedCrossRefGoogle Scholar
  12. 12.
    Stanczyk M, Deveney CW, Traxler SA, McConnell DB, Jobe BA, O’Rourke RW. Gastro–gastric fistula in the era of divided Roux-en-Y gastric bypass: strategies for prevention, diagnosis, and management. Obes Surg 2006;16(3):359–364.PubMedCrossRefGoogle Scholar
  13. 13.
    Cucchi SG, Pories WJ, MacDonald KG, Morgan EJ. Gastrogastric fistulas. A complication of divided gastric bypass surgery. Ann Surg 1995;221(4):387–391.PubMedCrossRefGoogle Scholar
  14. 14.
    Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Villares A, Zundel N, Rosenthal R. 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. Surg Obes Relat Dis 2005;1(5):467–474.PubMedCrossRefGoogle Scholar
  15. 15.
    Gumbs AA, Duffy AJ, Bell RL. Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2(2):117–121.PubMedCrossRefGoogle Scholar
  16. 16.
    Gastrointestinal surgery for severe obesity. Consens Statement 1991;9(1):1–20.Google Scholar
  17. 17.
    Szomstein S. How we do it: laparoscopic Roux-en-Y gastric bypass. Contemp Surg 2007;62(3):106–111.Google Scholar
  18. 18.
    Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB, Provost DA. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2003;17(5):679–684.PubMedCrossRefGoogle Scholar
  19. 19.
    Favretti F, Segato G, De MF, Pucciarelli S, Nitti D, Lise M. Malfunctioning of linear staplers as a cause of gastro–gastric fistula in vertical gastroplasty]. G Chir 1990;11(3):157–158.PubMedGoogle Scholar
  20. 20.
    Shikora SA, Kim JJ, Tarnoff ME. Reinforcing gastric staple-lines with bovine pericardial strips may decrease the likelihood of gastric leak after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13(1):37–44.PubMedCrossRefGoogle Scholar
  21. 21.
    Sapala JA, Wood MH, Schuhknecht MP. Anastomotic leak prophylaxis using a vapor-heated fibrin sealant: report on 738 gastric bypass patients. Obes Surg 2004;14(1):35–42.PubMedCrossRefGoogle Scholar
  22. 22.
    Lee MG, Provost DA, Jones DB. Use of fibrin sealant in laparoscopic gastric bypass for the morbidly obese. Obes Surg 2004;14(10):1321–1326.Google Scholar
  23. 23.
    Zorrilla PG, Salinas RJ, Salinas-Martinez AM. Vertical banded gastroplasty–gastric bypass with and without the interposition of jejunum: preliminary report. Obes Surg 1999;9(1):29–32.PubMedCrossRefGoogle Scholar
  24. 24.
    Filho AJ, Kondo W, Nassif LS, Garcia MJ, Tirapelle RA, Dotti CM. Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass. JSLS 2006;10(3):326–331.PubMedGoogle Scholar
  25. 25.
    Gould JC, Garren MJ, Starling JR. Lessons learned from the first 100 cases in a new minimally invasive Bariatric surgery program. Obes Surg 2004;14(5):618–625.PubMedCrossRefGoogle Scholar
  26. 26.
    Sims TL, Mullican MA, Hamilton EC, Provost DA, Jones DB. Routine upper gastrointestinal Gastrografin swallow after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13(1):66–72.PubMedCrossRefGoogle Scholar
  27. 27.
    Rasmussen JJ, Fuller W, Ali MR. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc 2007 19.Google Scholar
  28. 28.
    Carrodeguas L, Szomstein S, Zundel N, Lo ME, Rosenthal R. Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery: analysis of 1291 patients. Surg Obes Relat Dis 2006;2(2):92–97.PubMedCrossRefGoogle Scholar
  29. 29.
    Gumbs AA, Duffy AJ, Bell RL. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis 2006;2(4):460–463.PubMedCrossRefGoogle Scholar
  30. 30.
    Gustavsson S, Sundbom M. Excellent weight result after Roux-en-Y gastric bypass in spite of gastro–gastric fistula. Obes Surg 2003;13(3):457–459.PubMedCrossRefGoogle Scholar
  31. 31.
    MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP. Stomal ulcer after gastric bypass. J Am Coll Surg 1997;185(1):1–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Siilin H, Wanders A, Gustavsson S, Sundbom M. The proximal gastric pouch invariably contains acid-producing parietal cells in Roux-en-Y gastric bypass. Obes Surg 2005;15(6):771–777.PubMedCrossRefGoogle Scholar
  33. 33.
    Hedberg J, Hedenstrom H, Nilsson S, Sundbom M, Gustavsson S. Role of gastric acid in stomal ulcer after gastric bypass. Obes Surg 2005;15(10):1375–1378.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2007

Authors and Affiliations

  1. 1.The Bariatric Institute and Division of Minimally Invasive Surgery, Cleveland Clinic FloridaWestonUSA

Personalised recommendations