Classification, surgical management and outcomes of patients with gastrogastric fistula after Roux-En-Y gastric bypass.

BACKGROUND: Gastrogastric fistula (GGF) is a known complication after Roux-en-Y gastric bypass that can lead to marginal ulceration (MU) and failure of weight loss. OBJECTIVES: To describe our experience with GGF management and propose a classification of GGF based on its anatomic location. SETTING: University hospital, France. METHODS: After internal review board approval, data from all patients with a GGF were reviewed. GGF was classified as type 1 when located in the proximal part of the gastric pouch and type 2 when located near the gastrojejunostomy. RESULTS: Nine patients developed a GGF (.5%). GGF symptoms included epigastric pain (78%), vomiting (11%), gastrointestinal bleeding (11%), and weight regain (44%). Upper contrast study identified GGF in all patients. Upper endoscopy confirmed GGF in 6 patients, all with type 2. Eight patients required revisional surgery. Patients with type 1 GGF (n = 3) had excision of the fistulous tract. Patients with type 2 GGF (n = 5) had associated revision of the gastrojejunostomy. Mean operative time was significantly longer for type 2 GGF. The mean follow-up was 43 months, with no patient lost. One patient developed a recurrent MU requiring iterative revision. After that, all revisional patients were symptom free and the mean body mass index was 35.3±9.5 kg/m². CONCLUSION: Weight regain and epigastric pain with or without associated MU are the most common signs of GGF. Combining upper gastrointestinal endoscopy and contrast study is the best method to confirm the diagnosis. Surgical treatment should be tailored to both GGF location and status of the gastrojejunostomy. Based on its anatomic location, GGF classification could serve as a working basis to compare different surgical approaches.

Ten cases of gastro-tracheobronchial fistula: a serious complication after esophagectomy and reconstruction using posterior mediastinal gastric tube.

Gastro-tracheobronchial fistula (GTF) is a rare but life-threatening complication specifically observed after esophagectomy and reconstruction using posterior mediastinal gastric tube. Ten cases of GTF were encountered in three hospitals in 2000-2009. Their clinicopathological, surgical, and postoperative care are summarized, together with a review of previously reported cases. GTF was classified as anastomotic leakage (n= 5), gastric necrosis (n= 4), and gastric ulcer type (n= 1). The anastomotic leakage type appeared about 2 weeks (postoperative day [POD]: 8-35) after esophagectomy, was located in the cervical or higher thoracic trachea. Breathing and pneumonia were controlled by tracheal tube placed in the distal of fistula. The gastric necrosis type was noted in patients who developed necrosis of the upper part of the gastric tube and abscess formation behind the tracheal wall, at POD 20-36 around the carina, the site of pronounced ischemia. Due to the large fistula around the carina, emergency surgery with muscle patch repair was frequently required for the control of aspiration pneumonia. Patients of the gastric ulcer type had peptic ulcer in the lesser curvature of the gastric tube, which perforated into the right bronchus long after surgery (POD 630). With respect to tracheobronchial factors, preoperative chemoradiation (three cases) and pre-tracheal node dissection (three cases) tended to increase the risk of GTF. Closure of GTF by surgery (muscle patch repair) was successful in four cases and by nonsurgical treatment in three cases. In one case, stable oral intake was achieved by bypass operation without closure of GTF. Hospital death occurred in three cases. Understanding the pathogenesis and treatment options of GTF is important for surgeons who deal with esophageal cancer.

Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation.

Fistulas are abnormal communications between two epithelial-lined surfaces. Gastrointestinal fistulas encompass all such connections that involve the alimentary tract, and they can be congenital or acquired in nature. This review focuses on acquired gastrointestinal fistulas. Development of an acquired gastrointestinal fistula can greatly affect patient outcome, yet the clinical manifestations are often protean in nature and the etiology, elusive. Imaging plays an important role in the detection and management of acquired gastrointestinal fistulas. The more routine use of cross-sectional imaging (especially computed tomography and magnetic resonance imaging) has altered the standard sequence of radiologic evaluation for possible fistulas, but fluoroscopic studies remain a valuable complement, especially for confirming and defining the anomalous communications. In this review, a classification scheme for gastrointestinal fistulas is provided, major causes are discussed, and individual fistula types are elaborated with an emphasis on contemporary imaging approaches.

Experiencia de manejo de los pacientes con fistula gastrointestinal y soporte nutricional en la Clinica San Pedro Claver, 1999 / Experience in managemetn of patients with gastrointestinal fistula y nutritional support

Las fístulas gastrointestinales constituyen una de las condiciones médico-quirúrgicas de más difícil tratamiento; a pesar de los avances en la técnica quirúrgica, antibióticos y soporte nutricional, conllevan a una considerable morbimortalidad, una prolongada estancia hospitalaria, altos costos para el paciente y la institución que lo atiende. Se realizó un estudio descriptivo, evaluativo, retrospectivo del tipo de serie de casos durante un período de un año, comprendido de enero 1 de 1999 a enero 1 de 2000. Se evaluaron 40 pacientes, 20 hombres y 20 mujeres, todos con fístulas gastrointestinales posoperatorias, 6 esofágicas, 3 gástricas, 2 duodenales, 7 biliares, 2 pancreáticas, 16 de intestino delgado y 4 de colon. El promedio de estancia hospitalaria fue de 24.2 días y no se tuvieron en cuenta dos pacientes que requirieron nutrición parenteral ambulatoria. La mortalidad global fue del 25 por ciento. cifra superior a los promedios de trabajos similares, explicado por la alta incidencia de cáncer, enteritis posirradiación y edad del grupo de pacientes estudiados. También o explica el que la Clínica San Pedro Claver, como cabeza en la pirámide de todas las clínicas del Seguro Social, recibe todos los traslados de los pacientes complicados que no pueden ser tratados en las diferentes clínicas del país

Communicating bronchopulmonary foregut malformations: classification and embryogenesis.

Communicating bronchopulmonary foregut malformations (CBPFMs) are characterized by a fistula between an isolated portion of respiratory tissue (ie, a lung, a lung lobe, or a segment) and esophagus or stomach. We combine our 30-year (1959 to 1989) experience of 6 cases with 51 reported patients to propose a CBPFM classification supported by a proposed embryogenesis theory. Group I (16%): anomaly is associated with esophageal atresia and tracheoesophageal fistula. Group II (33%): one lung originates from the lower esophagus. Group III (46%): an isolated anatomic lung lobe or segment communicates with the esophagus or stomach. Group IV (5%): A portion of the normal bronchial system communicates with the esophagus. The portion of the lung served by the communicating bronchus receives systemic blood supply. The right and left lung sacs curve dorsally to embrace the lower esophagus during normal lung development. At this stage a part of the lung bud joins the esophagus. This segment then breaks away from the main pulmonary anlage to form a CBPFM. CBPFMs should be considered in the workup of infants with respiratory distress and/or recurrent pneumonias. Patients with suspected pulmonary sequestration should undergo contrast studies to exclude a gastrointestinal communication.