Background

This case demonstrates laparoscopic en bloc resection of gastrogastric fistula with esophagojejunostomy for severe penetrating marginal ulcer disease after Roux-en-Y gastric bypass.

Methods

The patient is a 42 year old female with history of Roux-en-Y gastric bypass in 2006, complicated by marginal ulcer in 2016 with gastrojejunal stricture. She presented in 2020 with dysphagia, epigastric pain, melena, and anemia. An upper GI series was performed demonstrating a gastrogastric fistula and gastrojejunal ulcerations, confirmed on upper endoscopy. Despite 3 weeks of PPI and TPN, her symptoms did not improve, and surgery was indicated. A penetrating marginal ulcer fistulizing into the remnant and the left liver lobe was encountered. After extensive adhesiolysis, a total pouch and remnant gastrectomy was performed with a small liver wedge, and an esophagojejunostomy was created. Barium swallow postoperative day 1 demonstrated normal passage of contrast through the anastomosis and no leak. She gradually started liquids and postoperative wound and abdominal abscesses were treated with percutaneous drainage and antibiotics. At 6 weeks postoperatively she was stable and tolerating diet.

Results

Untreated or nonhealing marginal ulcers may lead to bleeding, stricture, perforation or fistula, including a gastrogastric fistula in up to half of patients. Gastrogastric fistulas in turn predispose to nonhealing marginal ulceration. If medical treatment is unsuccessful, surgery is indicated for definitive management. Severe cases may require remnant or total gastrectomy; the latter involving new roux-en-y reconstruction.

Conclusions

Nonhealing marginal ulcers may lead to severe complications including gastrogastric fistula. Refractory cases require definitive surgical resection.