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 ¤  Abstract
 ¤ Introduction
 ¤ Case report
 ¤ Discussion
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 Table of Contents     
UNUSUAL CASE
Year : 2014  |  Volume : 10  |  Issue : 4  |  Page : 216-218
 

Laparoscopic repair of gastro-duodenal fistula secondary to band erosion


Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA

Date of Submission31-May-2014
Date of Acceptance03-Aug-2014
Date of Web Publication23-Sep-2014

Correspondence Address:
Kunal J Patel
96 Jonathan Lucas Street, Charleston, SC 29425, South Carolina
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.141533

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 ¤ Abstract 

Laparoscopic gastric banding is one of the most common surgical treatments for morbid obesity performed worldwide. The procedure, however, has many well-documented risks and complications, including band erosion. We present here a gastric banding patient who was referred to our tertiary care centre after secondarily forming an entero-enteric fistula with complaints of pain, nausea, vomiting and severe reflux. She was successfully treated with laparoscopic dissection and due to her existing anatomy, and the patient's desire for continued weight loss, she was converted to Roux-en-Y gastric bypass.


Keywords: Fistula, gastric banding, gastric bypass, gastric erosion, lap band, laparoscopy, morbid obesity, Roux-en-Y


How to cite this article:
Patel KJ, Byrne T K, Pullatt RC. Laparoscopic repair of gastro-duodenal fistula secondary to band erosion . J Min Access Surg 2014;10:216-8

How to cite this URL:
Patel KJ, Byrne T K, Pullatt RC. Laparoscopic repair of gastro-duodenal fistula secondary to band erosion . J Min Access Surg [serial online] 2014 [cited 2019 Dec 11];10:216-8. Available from: http://www.journalofmas.com/text.asp?2014/10/4/216/141533



 ¤ Introduction Top


Despite early optimism for laparoscopic gastric band surgery, this intervention for morbid obesity has since shown itself predisposed to various complications. One of the well-described complications is band erosion, which has been reported to occur in 2-10% of all gastric band patients, with some small series reporting 34% erosion rate. [1],[2] Recommended intervention includes removal and repair, and if continued weight loss is desired, either delayed replacement or alternative surgical therapy. [1],[3] We describe here the management of a patient with gastric erosion and the unusual added complication of fistula formation.


 ¤ Case report Top


SB is a 70-year-old female with a history of previous gastric band placement in 2008 at an outside hospital. In 2010, she began having issues with chest pain, nausea and vomiting and was subsequently found to have band erosion and oesophageal perforation that was treated surgically with band removal and closure. An upper gastrointestinal (GI) series performed shortly after the procedure showed a persistent fistulous tract between the gastro-oesophageal junction and the duodenal bulb that almost entirely bypassed the excluded stomach. Initial management was medical and included proton pump inhibitor therapy. She continued to have heartburn and dysphagia, with eventual recurrence of nausea and vomiting. Subsequent oesophagogastroduodenoscopy by her gastroenterologist revealed duodenal strictures, and an attempt was made to repair the fistula endoscopically with clips. Persistence of the fistulous tract led to her referral for surgical intervention.

Upon referral to our facility, pre-operative computed tomography imaging of the abdomen demonstrated a persistent gastro-duodenal fistula with subsequent angulation and narrowing of the pylorus-duodenal junction secondary to tethering [Figure 1]. The decision was made to proceed to the operating room for division and takedown of the fistula.
Figure 1: Pre-operative computed tomography of the abdomen. The proximal duodenum is tethered to the proximal stomach creating a very small pylorus lumen

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The procedure was performed laparoscopically with intra-operative upper endoscopy for the full evaluation of gastric and duodenal anatomy. The endoscope was able to be passed post-pyloric, however was restricted thereafter due to the kinking of the duodenum. Extensive lysis of adhesions was undertaken as the left lobe of the liver was adhered to the stomach. The fistulous tract was then identified in close proximity to the porta hepatis, and was carefully dissected and divided using an Endo GIA stapler [Figure 2]. The decision was then made that, due to the acute angulation and the chronic inflammation that the fistula had created coupled with the patient's desire for continued weight loss, to convert her to a partial gastrectomy with a Roux-en-Y reconstruction.

Post-operatively, the patient did very well. An upper GI barium swallow was performed on post-operative day 1 (POD-1), which showed intact anastomoses consistent with successful Roux-en-Y gastric bypass (RYGB), as well as, closure of the fistulous tract [Figure 3]. The patient was advanced on normal post-gastric bypass diet perinstitutional protocol and was discharged home on POD-2 with minimal complaints of nausea or continued reflux.
Figure 2: Closure and division of gastro-duodenal fistula with a single fire of the green load Echelon staples

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Figure 3: Post-surgical changes following partial gastrectomy and Roux-en-Y bypass. There is beaking of contrast in the prior fistula tract, which is no longer patent

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At routine post-operative follow-up, the patient was doing well. She reported continued issues with reflux, however at her 6 months post-operative visit; this had essentially resolved. She was tolerating a regular diet, and her blood sugars remained well-controlled.


 ¤ Discussion Top


Band erosion is a known complication of laparoscopic gastric band surgery. [1],[2],[3],[4] In our patient, the exact aetiology remains unclear, and primary duodenal pathology is a possibility for her unusual presentation, however, we believe that the fistulous tract was most likely the result of local and post-surgical inflammation after her band removal procedure for her initial oesophageal erosion in 2010. Our patient secondarily formed an entero-enteric fistula and was successfully treated with laparoscopic dissection. Due to her existing anatomy, the patient's desire for continued weight loss and fear that her diabetes, previously cured by gastric banding, would recur, she was converted to RYGB.

Roux-en-Y gastric bypass has been described as a safe and effective salvage procedure in patients with previous failed adjustable gastric banding, and indeed, is considered to be the "gold standard" revision procedure for failed bariatric surgeries. A study analysing 82 patients showed that laparoscopic RYGB after failed gastric banding for any of a number of complications produced adequate weight loss, and more importantly, was effective at resolving adverse symptoms. [3] However, only seven of these patients demonstrated band erosion, and none were reported to have a severe complication similar to that of our patient. Nevertheless, this patient's anatomy lent itself well to RYGB, especially after repair of fistulous tract, and she has demonstrated remarkable recovery post-operatively.

 
 ¤ References Top

1.Brown WA, Egberts KJ, Franke-Richard D, Thodiyil P, Anderson ML, O'Brien PE. Erosions after laparoscopic adjustable gastric banding: Diagnosis and management. Ann Surg 2013;257:1047-52.  Back to cited text no. 1
    
2.Suter M, Calmes JM, Paroz A, Giusti V. A 10-year experience with laparoscopic gastric banding for morbid obesity: High long-term complication and failure rates. Obes Surg 2006;16:829-35.  Back to cited text no. 2
    
3.Hii MW, Lake AC, Kenfield C, Hopkins GH. Laparoscopic conversion of failed gastric banding to Roux-en-Y gastric bypass: Short-term follow-up and technical considerations. Obes Surg 2012;22:1022-8.  Back to cited text no. 3
    
4.Egberts K, Brown WA, O'Brien PE. Systematic review of erosion after laparoscopic adjustable gastric banding. Obes Surg 2011;21:1272-9.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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