Background

Gastro-Abdominal fistula formation are an uncommon complication as a result of a Roux-en-y Gastric bypass. The reported incidence varies anywhere from 0.6% to as much as 16% for gastroinestinal fistulas, however the pathogenesis, and definitions have not been clearly defined, especially for gastro-abdominal fistulas (GAF). Currently, risk factors associated with GAF are diabetes, smoking, and prior history of peptic ulcer disease. A 67 y/o female with a history of a laparoscopic Roux-en-y gastric bypass 3 years prior. Patient had presented with chronic marginal ulceration, and several episodes of hematemesis. Patient acutely presented with septic shock, with CT scan evidence of a gastro-abdominal fistula, along with intra-abdominal and intra-hepatic abscesses.

Methods

Patient underwent a diagnostic laparoscopy, with lysis of adhesions, and drainage of peri-splenic abscess, and intra-operative EGJ and stent placement across the fistula. Patient had drainage of the intra-hepatic abscess by Interventional Radiology. She underwent a series of upper endoscopies, with replacement of Gastro-jejunal stent following the initial procedure.

Results

Ultimately, she was taken back for repeat laparoscopy, with partial gastrectomy of remnant stomach, and gastrorrhaphy of gastric pouch.

Conclusions

While the patient did require repeat trips to the operating room, we demonstrated that operative drainage of intra-abdominal abscess, along with GJ stenting and IR drainage of the intra-hepatic abscesses to initially treat her sepsis followed by nutritional optimization and eventual laparoscopic revision of her gastric bypass was viable means of managing this complex problem.