Gastrogastric Fistula: an Unusual Cause for Severe Bile Reflux Following Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass

May 6, 2018Obesity surgery

Severe Bile Reflux Caused by an Uncommon Stomach Connection After Sleeve Gastrectomy is Changed to One Anastomosis Gastric Bypass

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Abstract

A 33-year-old patient experienced severe bile reflux after conversion from sleeve gastrectomy to one anastomosis gastric bypass.

Postoperative complications included epigastric pain, worsening reflux symptoms, steatorrhea, and hypoproteinemia.
Preoperative endoscopy revealed bile reflux, a suture bezoar, and ulceration at the anastomosis site.
Intraoperative findings included a gastrogastric fistula, which was confirmed through endoscopy.
The gastrogastric fistula, an unusual cause of bile reflux, had not been previously reported.
After resection of the fistula and conversion to Roux-en-Y gastric bypass, the patient had an uneventful recovery.

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INTRODUCTION: One anastomosis gastric bypass/mini-gastric bypass (OAGB/MGB) was first described in 2001 as a safe and effective procedure. It has been gaining popularity worldwide. Multiple authors have reported the need to re-operate on patients for bile reflux. We report a patient with severe bile reflux after laparoscopic conversion of sleeve gastrectomy (LSG) to OAGB/MGB.

METHODS: A 33-year-old patient underwent a LSG in 2014. Postoperatively, she developed severe gastroesophageal acid reflux. In 2016, she underwent conversion of LSG to OAGB/MGB at the original institution for the treatment of her reflux symptoms. In 2017, she presented to us with epigastric pain, worsening reflux symptoms, steatorrhea, hypoproteinemia (6 g/dl), and body mass index of 25 kg/m. Preoperative endoscopy revealed bile reflux, suture bezoar, and ulceration at the anastomosis. 2

TECHNIQUE: Laparoscopic exploration started by identifying the anatomy and measuring the lengths of the biliopancreatic limb (350 cm) and the common channel (450 cm). Upon dissecting the pouch, a gastrogastric fistula extending from the antrum to the pouch was encountered. This was confirmed with intraoperative endoscopy with bile refluxing to the pouch. The fistula, antrum, and part of the pouch were resected. The patient was converted to Roux-en-Y gastric bypass. She had an uneventful postoperative recovery. At 3 months of follow-up, her weight was stable and her steatorrhea resolved.

CONCLUSION: Patients with bile reflux after OAGB/MGB need a high index of suspicion to detect unusual causes. Gastrogastric fistula is an unusual etiology of bile reflux that was never reported in the literature previously.

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Gastrogastric Fistula: an Unusual Cause for Severe Bile Reflux Following Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass

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