Endoscopy 2018; 50(06): E132-E133
DOI: 10.1055/s-0044-101829
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic sleeve gastroplasty of the remnant stomach in Roux-en-Y gastric bypass: a novel approach to a gastrogastric fistula with weight regain

Allison R. Schulman
1  Brigham and Women’s Hospital, Boston, Massachusetts, USA
,
Mustafa Huseini
1  Brigham and Women’s Hospital, Boston, Massachusetts, USA
,
Christopher C. Thompson
1  Brigham and Women’s Hospital, Boston, Massachusetts, USA
2  Harvard Medical School, Boston, Massachusetts, USA
› Author Affiliations
Further Information

Corresponding author

Christopher Thompson, MD
Division of Gastroenterology
Brigham and Women’s Hospital
75 Francis St. ASBII
Boston
Massachusetts 02115
USA   
Fax: +1-617-264-6342    

Publication History

Publication Date:
22 March 2018 (eFirst)

 

    A gastrogastric fistula is a channel that develops between the gastric pouch and gastric remnant following a Roux-en-Y gastric bypass (RYGB). The management includes symptom control, high dose acid suppression, and consideration of closure techniques for those with persistent symptoms. While endoscopic approaches are less invasive than surgical repair, less than one-third of fistulas remain closed. Here, we demonstrate a novel approach whereby we performed endoscopic sleeve gastroplasty (ESG) of the remnant stomach through the gastrogastric fistula, followed by reduction in volume of the gastric pouch ([Video 1]).

    Video 1 Endoscopic sleeve gastroplasty of the remnant stomach following a Roux-en-Y gastric bypass as a treatment for gastrogastric fistula with weight regain.


    Quality:

    A 56-year-old man with a history of RYGB performed 13 years previously presented with weight regain of 100 pounds over 1 year. Index endoscopy showed a 3-cm gastrogastric fistula with an ulcerated and completely stenotic gastrojejunal anastomosis ([Fig. 1 a]). We began the procedure by marking the estimated midline on the posterior surface of the stomach using argon plasma coagulation (APC), so we could ensure that stitches were placed only on the greater curvature side of this line ([Fig. 1 b]). The endoscopic suturing device was then advanced through the gastrogastric fistula. A series of six running stitches were placed in a triangular pattern (anterior, greater curvature, posterior configuration), and this was repeated five to seven times ([Fig. 1 c]). This particular stitch pattern has the effect of longitudinally contracting the stomach to pull down the fundus, while moving from the antrum proximally ([Fig. 1 d]).

    Zoom Image
    Fig. 1 Endoscopic images showing: a a gastrogastric fistula (three arrows) with an ulcerated and stenotic gastrojejunal anastomosis (single arrow); b the posterior surface of the remnant stomach, which has been marked by argon plasma coagulation; c endoscopic stitches placed in a triangular pattern; d the appearance following successful endoscopic sleeve gastroplasty of the remnant stomach.

    Following successful ESG, the volume of the gastric pouch is reduced, thereby shunting oral intake through the gastrogastric fistula and into the repaired remnant stomach. An upper gastrointestinal contrast study demonstrated that enteric contrast filled a small gastric pouch then opacified the remnant stomach followed by the duodenum, rather than passing through the gastrojejunostomy ([Fig. 2]).

    Zoom Image
    Fig. 2 Image from an upper gastrointestinal contrast study showing enteric contrast filling a small gastric pouch then opacifying the remnant stomach followed by the duodenum, rather than passing through the gastrojejunostomy.

    In conclusion, ESG of the gastric remnant through an existing gastrogastric fistula is a novel, technically feasible, and effective treatment for weight regain following RYGB.

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    Competing interests

    C. Thompson has acted as a consultant and received research support from Apollo Endosurgery, Inc. and Olympus; has been a consultant for Boston Scientific; and has been a consultant, and received royalties and stock from Covidien.


    Corresponding author

    Christopher Thompson, MD
    Division of Gastroenterology
    Brigham and Women’s Hospital
    75 Francis St. ASBII
    Boston
    Massachusetts 02115
    USA   
    Fax: +1-617-264-6342    


    Zoom Image
    Fig. 1 Endoscopic images showing: a a gastrogastric fistula (three arrows) with an ulcerated and stenotic gastrojejunal anastomosis (single arrow); b the posterior surface of the remnant stomach, which has been marked by argon plasma coagulation; c endoscopic stitches placed in a triangular pattern; d the appearance following successful endoscopic sleeve gastroplasty of the remnant stomach.
    Zoom Image
    Fig. 2 Image from an upper gastrointestinal contrast study showing enteric contrast filling a small gastric pouch then opacifying the remnant stomach followed by the duodenum, rather than passing through the gastrojejunostomy.