1. Endoscopy/Port Placement

2. Lysis of Adhesions and Hiatal Dissection

3. Vagotomy

4. Hiatal Hernia Repair

5. Division of Roux Limb

a. Remove Adhesions and Mesentery

b. Dissection of stomach

c. Division of Gastric Remnant

d. Dissection of Remnant Off of Pouch

e. Dissection of Remnant/Pouch/Roux Limb Confluence (Resection of Ulcer)

f. Completion of Remnant Dissection

6. Partial Gastrectomy/Resection of Ulcer

a. Oversew Staple Line of Remnant

b. Mobilize Jejunal Mesentery

c. Evaluation of Jejunal Anastomosis

d. Evaluation of Jejunal Common Channel

e. Division of Attachments of Roux Limb to Mesocolon

f. Identification of Ligament Treitz/Creation of Mesocolonic Window

g. Passage of Jejunum through Transverse Mesocolon

7. Rerouting of Roux Limb

a. First layer of Anastomosis

b. Testing of Anastomosis

c. Second Layer of Anastomosis

8. New GJ Anastomosis

9. Endoscopy for Testing of Anastomosis

10. Closure

Gastrogastric fistula is a rare complication following a roux-en-y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, reflux, poor weight loss, and weight regain. Etiologies include postoperative Roux-en-Y gastric bypass leaks, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of a foreign body. Diagnosis is made through upper gastrointestinal contrast radiography or CT scan and endoscopy. Barium contrast radiography is particularly useful and is the preferred initial study method for the detection of staple-line dehiscence, which may be small and overlooked during endoscopy. Once identified, a gastrogastric fistula may be treated surgically with remnant gastrectomy or gastrojejunostomy revision. Here, we present a case of a female patient status post Roux-en-Y gastric bypass surgery who presented with abdominal pain. Upon endoscopy, she was noted to have an inflamed gastric pouch and a gastogastric fistula. A laparoscopic gastric bypass revision was done to divide the gastrogastric fistula and to separate the gastric pouch from the gastric remnant in order to alleviate the inflamed gastric pouch and prevent further ulcer formation.

Massachusetts General Hospital

Laparoscopic Gastric Bypass Revision

0104 - Pratt 5-21-2015.mp4

0104 - Pratt

Gastrogastric fistula is a rare complication following a roux-en-y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, r...

Laparoscopic Gastric Bypass Revision | Journal of Medical Insight

DOI
Publication Date	N/A
Article ID	25
Production ID	0104
Volume	N/A
Issue	25
https://doi.org/10.24296/jomi/25

Laparoscopic Gastric Bypass Revision

Procedure Outline

Table of Contents

Anesthesia

Patient Positioning

Endoscopy/Port Placement

Lysis of Adhesions and Hiatal Dissection

Surgical Intervention

Vagotomy

Hiatal Hernia Repair

Division of Roux Limb

Partial Gastretomy/Resection of Ulcer

Rerouting of Roux limb

New GJ Anastomosis

Endoscopy for Testing of Anastomosis

Closure