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Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction
Journal Pre-proof Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction Mohamad I. Itani, Lea Fayad, Ahmed El Nahla, Jad Farha, Vivek Kumbhari PII:
S0016-5107(20)30058-4
DOI:
https://doi.org/10.1016/j.gie.2020.01.032
Reference:
YMGE 11948
To appear in:
Gastrointestinal Endoscopy
Received Date: 15 July 2019 Accepted Date: 21 January 2020
Please cite this article as: Itani MI, Fayad L, El Nahla A, Farha J, Kumbhari V, Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction, Gastrointestinal Endoscopy (2020), doi: https://doi.org/10.1016/j.gie.2020.01.032. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020 by the American Society for Gastrointestinal Endoscopy
Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction Mohamad I. Itani1, Lea Fayad1, Ahmed El Nahla2, Jad Farha1, Vivek Kumbhari1 Institution: 1. Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, United States. 2. Cairo University Faculty of Medicine, Cairo, Egypt. Corresponding Author Vivek Kumbhari, MD Associate Professor of Medicine Director of Bariatric Endoscopy Johns Hopkins Medicine, Division of Gastroenterology and Hepatology 1800 Orleans St. Sheikh Zayed Tower, Suite 7125B Baltimore, MD 21224 Email: [email protected]
Authors Mohamad I. Itani, MD Division of Gastroenterology Johns Hopkins Medical Institutions Baltimore, Maryland, USA [email protected]
Lea Fayad, MD Division of Gastroenterology Johns Hopkins Medical Institutions Baltimore, Maryland, USA [email protected]
Jad Farha, MD Division of Gastroenterology Johns Hopkins Medical Institutions Baltimore, Maryland, USA [email protected]
Ahmed Elnahla, MD Senior Registrar Cairo University Faculty of Medicine Cario, Egypt [email protected]
Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction Mohamad I. Itani, Lea Fayad, Jad Farha, Ahmed El Nahla, Vivek Kumbhari A 48-year-old male with a history of Roux-en-Y gastric bypass presented for weight regain. Previous EGD revealed widely patent gastrojujenal anastomosis (GJ); therefore, the decision was made to preform transoral gastric outlet reduction (TORe) (A). The endoscope was introduced up to the proximal jejunum and revealed a moderate residual gastric pouch with 5 cm of gastric tissue distal to the Z-line, widely patent GJ measuring 30 mm. The patient underwent TORe, where the lumen was reduced to 8 mm in diameter (B) and was scheduled for follow-up EGD after 8 weeks. Follow-up EGD revealed a 16 mm GJ, a large anastomotic gastric ulcer, and a new gastrogastric fistula (C). The gastrogastric fistula was entered and the endoscope was advanced to D2. The patient was prescribed high-dose PPIs and was scheduled for follow-up EGD after 8 weeks. Follow-up EGD revealed a 12-mm diameter GJ, 5-mm clean-based ulcer at 10 o'clock, and a persistent 14-mm gastrogastric fistula (D). Because the size of the fistula was greater than 10 mm, endoscopic techniques for closure would inevitably be unsuccessful; therefore, the patient was referred for surgical fistula closure. This is the first case linking TORe with gastrogastric fistula. The likely cause of the fistula stems from the aggressive argon plasma coagulation performed for mucosal devitalization to promote a successful TORe. The main concern in this case is marginal ulceration, which is due to acid secretion from the excluded stomach entering the pouch and Roux limb.
S0016-5107(20)30058-4
DOI:
https://doi.org/10.1016/j.gie.2020.01.032
Reference:
YMGE 11948
To appear in:
Gastrointestinal Endoscopy
Received Date: 15 July 2019 Accepted Date: 21 January 2020
Please cite this article as: Itani MI, Fayad L, El Nahla A, Farha J, Kumbhari V, Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction, Gastrointestinal Endoscopy (2020), doi: https://doi.org/10.1016/j.gie.2020.01.032. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020 by the American Society for Gastrointestinal Endoscopy
Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction Mohamad I. Itani1, Lea Fayad1, Ahmed El Nahla2, Jad Farha1, Vivek Kumbhari1 Institution: 1. Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, United States. 2. Cairo University Faculty of Medicine, Cairo, Egypt. Corresponding Author Vivek Kumbhari, MD Associate Professor of Medicine Director of Bariatric Endoscopy Johns Hopkins Medicine, Division of Gastroenterology and Hepatology 1800 Orleans St. Sheikh Zayed Tower, Suite 7125B Baltimore, MD 21224 Email: [email protected]
Authors Mohamad I. Itani, MD Division of Gastroenterology Johns Hopkins Medical Institutions Baltimore, Maryland, USA [email protected]
Lea Fayad, MD Division of Gastroenterology Johns Hopkins Medical Institutions Baltimore, Maryland, USA [email protected]
Jad Farha, MD Division of Gastroenterology Johns Hopkins Medical Institutions Baltimore, Maryland, USA [email protected]
Ahmed Elnahla, MD Senior Registrar Cairo University Faculty of Medicine Cario, Egypt [email protected]
Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction Mohamad I. Itani, Lea Fayad, Jad Farha, Ahmed El Nahla, Vivek Kumbhari A 48-year-old male with a history of Roux-en-Y gastric bypass presented for weight regain. Previous EGD revealed widely patent gastrojujenal anastomosis (GJ); therefore, the decision was made to preform transoral gastric outlet reduction (TORe) (A). The endoscope was introduced up to the proximal jejunum and revealed a moderate residual gastric pouch with 5 cm of gastric tissue distal to the Z-line, widely patent GJ measuring 30 mm. The patient underwent TORe, where the lumen was reduced to 8 mm in diameter (B) and was scheduled for follow-up EGD after 8 weeks. Follow-up EGD revealed a 16 mm GJ, a large anastomotic gastric ulcer, and a new gastrogastric fistula (C). The gastrogastric fistula was entered and the endoscope was advanced to D2. The patient was prescribed high-dose PPIs and was scheduled for follow-up EGD after 8 weeks. Follow-up EGD revealed a 12-mm diameter GJ, 5-mm clean-based ulcer at 10 o'clock, and a persistent 14-mm gastrogastric fistula (D). Because the size of the fistula was greater than 10 mm, endoscopic techniques for closure would inevitably be unsuccessful; therefore, the patient was referred for surgical fistula closure. This is the first case linking TORe with gastrogastric fistula. The likely cause of the fistula stems from the aggressive argon plasma coagulation performed for mucosal devitalization to promote a successful TORe. The main concern in this case is marginal ulceration, which is due to acid secretion from the excluded stomach entering the pouch and Roux limb.