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

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.

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]).

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]).

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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