Case report about the management of a late Gastro-Gastric Fistula after Laparoscopic Gastric Bypass, with the finding of an unexpected foreign body

Highlights • Anemia & Weight Regain are possible signs of Gastrogastric fistula post RYGB.• Preventive Gastrectomy is indicated in presence of Dysplasia in the Gastric Remnant.• Orogastric Tube Stapling can be immediately detected or discovered years after RYGB.• A series of protocols should be respected to avoid Orogastric Tube Stapling.


Introduction
The work has been reported in line with the SCARE criteria [1]. Driven by the increase in the epidemic of obesity worldwide, bariatric surgery has gained popularity in the last few decades. Bariatric surgery is considered the front line of morbid obesity treatment, with Gastric Bypass gaining popularity and still being considered as the gold standard. Gastro-Gastric Fistula is a known rare complication after Gastric Bypass surgery, opening an abnormal communication between the excluded gastric remnant and the neo gastric pouch. It can lead to weight regain, marginal ulcers and epigastric pain. The incidence varies from 1 to 6% [2][3][4][5][6].
Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remains a technically demanding surgery and orogastric tube stapling can occur during the performance of the gastrojejunal anastomosis. It is a rare yet dreadful complication in bariatric surgery.
Malignancy in the gastric remnant is very rare following gastric bypass surgeries. However, endoscopic evaluation and follow up remain very difficult due to the isolated nature of the pouch indicating that a dysplasia should not be ignored.

Case report
A 51-year-old patient, with a history of an efficient RYGB performed 3 years ago, presented with dizziness, light headedness and weight regain. Lab tests showed anemia with Hemoglobin 8.8 g/dl, iron deficiency, and controlled diabetes by HbA1c 6.4% (11.4% prior to LRYGB).
An   intestinal cells with a low-grade dysplasia, in the gastric remnant. Finally, the tip of a Faucher tube was found fixed in the blind pouch distally and could not be retrieved endoscopically (Fig. 1). Retrospectively, the written report of the gastrotraphin ® swallow that was performed on the 1st day post-op showed a normal passage, no sign of leakage and no foreign body was present in the gastric remnant.
Following both diagnoses, the patient underwent a laparoscopic subtotal gastrectomy with refashioning of the gastrojejunal anastomosis. The gastric remnant was resected completely, including the Faucher Tube of 20 cm, along the greater curvature (Fig. 2).
The two days follow-up course was uneventful. Gastrotraphin ® swallow on day 1 post-op, was normal. Anatomic pathology results showed inflammatory reactivity surrounding the Gastric Fistula site, in the absence of any residual signs of dysplasia or malignancy. The patient was seen at 6 months post-op without anemia, in good health, and with a 15 kg weight-loss.

Discussion
Gastro-Gastric Fistula is a rare but known complication of RYGB, resulting from a communication between the Capella pouch and the excluded stomach [7]. The incidence rate described in the literature is believed to be underestimated due to lack of follow up [2][3][4][5][6]. Patients with Gastro-Gastric Fistula may be asymptomatic and may present with nonspecific symptoms such as weight regain, epigastric pain, nausea, vomiting, sometimes anemia as in our case, and even bleeding [2][3][4][5]. An upper endoscopy and upper GI contrast study should be performed to confirm diagnosis [8]. Management of Gastro-Gastric Fistulas depends on the symptoms, size, location and its classification (according to Ribeiro-Parenti et al. type I or II) [9].
Type I: More than 1 cm above the gastrojejunal anastomosis Type II: Less than 1 cm above the gastrojejunal anastomosis In the case of type II or the presence of intractable marginal ulcers, the anastomosis should be resected and recreated [3,5,6,10].
In type I, conservative medical treatment consists of high PPI doses and should be started for symptomatic patients without weight regain. Small fistulas might close spontaneously on medical treatment alone [11]. Eventually, endoscopic repair can be safely used and shows great results for fistulas <10 mm in diameter. A variety of methods can be used including endoclips, endosutures, and stents [10,11].
In type II, surgical treatment remains the standard of care for large fistulas and those that fail conservative or endoscopic treatment. Multiple surgical options can be performed depending on the anatomical findings and the surgeon's preference. A simple fistulectomy could be eventually performed. However, due to the fear of marginal ulceration and increased risk of recurrence, a more radical remnant gastrectomy is recommended, with 87-100% symptom resolution [12,13].
Orogastric tube stapling is a seldomly reported complication of bariatric surgery, with an incidence of 0.5-1.2%, more often detected perioperatively with an immediate repair. These occurrences might be increased in motorized staplers due to less tactile perception.
However, very late stage, years after surgery as in our case, complications have rarely been reported in the literature and hence should be emphasized as they may lead to severe complications if unrecognized [14].
Early perioperative recognition and repair of these complications is very important to reduce morbidity, and prevention strategies should be implemented to avoid them. Active communication with anesthetists is imperative to ensure the mobility of the orogastric tube during stapling and complete removal by checking the tip integrity of the Faucher tube. There are many intraoperative cues a surgeon should be aware of to avoid these complications: failure of a stapler to fire correctly, deformity of the stapler jaws, the need to use excessive force to close a stapler and finally control of the integrity of the Faucher tube, when removed [15].
Malignancy post RYGB is a rare occurrence with only around 30 cases reported in the literature [16]. Detecting it is a real challenge due to the difficulty in reaching the blind gastric remnant endoscopically and the vague nature of the symptoms. Gastric mucosal dysplasia is usually treated with endoscopic resection and reevaluation with regular follow ups [17] prior to surgery. However, in this case, given the exceptional anatomy and the extreme difficulty to access the blind gastric remnant, the decision was made to perform a subtotal gastrectomy. Two cases were reported with a gastric carcinoma in situ and both were treated with a remnant gastrectomy [17].
In our case report, the final biopsies didn't find residual dysplasia on the Gastrojejunal site. A protective and selectively subtotal gastrectomy was performed anyway to eliminate both fistula recurrence and increased dysplasia.

Conclusion
The Remnant Gastrectomy, associated with pouch refashioning, remains the standard treatment and can be performed safely in Gastro-Gastric Fistula, type II. Orogastric tube accidental complications should be preferably identified perioperatively. Strict measures of prevention protocols and control should be implied to avoid such events. Finally, the surgeon should keep a