Obesity Surgery

, Volume 29, Issue 1, pp 23–27 | Cite as

Endoscopic Closure of Gastro-gastric Fistula After Gastric Bypass: a Technically Feasible Procedure but Associated with Low Success Rate

  • Catherine Tsai
  • Ulf Kessler
  • Rudolf Steffen
  • Hans Merki
  • Joerg ZehetnerEmail author
Original Contributions



Gastro-gastric fistulas (GGF) are reported to be as high as 12% after gastric bypass for treatment of morbid obesity. While different endoscopic methods are described, the management traditionally consists of surgical revision with high associated morbidity. The aim of the study was to assess feasibility, safety and success rate of endoscopic closure using an endoscopic suturing device.


From January 2016 to March 2018, we reviewed the electronic records of all patients undergoing endoscopic closure of a GGF with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA). Demographic details, procedure details, and outcome variables were recorded.


A total of six patients (M:F = 5:1) underwent endoscopic fistula closure. Five patients (83.3%) had a prior banded gastric bypass (with subsequent band removal). The median number of prior abdominal surgeries was 3, the mean time from bypass to endoscopic fistula closure was 5 years (range 1.1–10.4). While immediate complete endoscopic fistula closure was possible in 10 of 12 attempts in those six patients (83%), all patients had recurrent (persistent) fistulas at follow-up. After a mean follow-up time of 12 months, 83.3% had further laparoscopic converted to open (n = 2) or laparoscopic (n = 3) revisions with complete fistula closure. One patient is refusing further intervention.


Endoscopic gastro-gastric fistula closure with an endoscopic suturing device is feasible and safe. Unfortunately, due to the nature of gastro-gastric fistulas, permanent successful closure is rare. Therefore, the approach should be reserved for patients in whom a laparoscopic or open surgical attempt is impossible due to prior abdominal revisions.


Gastro-gastric fistula Endosurgery Endoscopic suturing Bypass 


Compliance with Ethical Standards

The study was approved by the local ethics review board.

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Pories WJ. Bariatric surgery: risks and rewards. J Clin Endocrinol Metab. 2008;93:S89–96.CrossRefGoogle Scholar
  2. 2.
    Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909–17.CrossRefGoogle Scholar
  3. 3.
    Simpfendorfer CH, Szomstein S, Rosenthal R. Laparoscopic gastric bypass for refractory morbid obesity. Surg Clin North Am. 2005;85:119–27. xCrossRefGoogle Scholar
  4. 4.
    Carrodeguas L, Szomstein S, Soto F, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005;1:467–74.CrossRefGoogle Scholar
  5. 5.
    Tucker ON, Szomstein S, Rosenthal RJ. Surgical management of gastro-gastric fistula after divided laparoscopic Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2007;11:1673–9.CrossRefGoogle Scholar
  6. 6.
    Cho M, Kaidar-Person O, Szomstein S, et al. Laparoscopic remnant gastrectomy: a novel approach to gastrogastric fistula after Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg. 2007;204:617–24.CrossRefGoogle Scholar
  7. 7.
    MacLean LD, Rhode BM, Nohr C, et al. Stomal ulcer after gastric bypass. J Am Coll Surg. 1997;185:1–7.CrossRefGoogle Scholar
  8. 8.
    Corcelles R, Jamal MH, Daigle CR, et al. Surgical management of gastrogastric fistula. Surg Obes Relat Dis. 2015;11:1227–32.CrossRefGoogle Scholar
  9. 9.
    Papavramidis ST, Eleftheriadis EE, Papavramidis TS, et al. Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant. Gastrointest Endosc. 2004;59:296–300.CrossRefGoogle Scholar
  10. 10.
    Spaun GO, Martinec DV, Kennedy TJ, et al. Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos). Gastrointest Endosc. 2010;71:606–11.CrossRefGoogle Scholar
  11. 11.
    Mukewar S, Kumar N, Catalano M, et al. Safety and efficacy of fistula closure by endoscopic suturing: a multi-center study. Endoscopy. 2016;48:1023–8.CrossRefGoogle Scholar
  12. 12.
    Niland B, Brock A. Over-the-scope clip for endoscopic closure of gastrogastric fistulae. Surg Obes Relat Dis. 2017;13:15–20.CrossRefGoogle Scholar
  13. 13.
    Lopez-Nava G, Galvao M, Bautista-Castaño I, et al. Endoscopic sleeve gastroplasty with 1-year follow-up: factors predictive of success. Endosc Int Open. 2016;4:E222–7.CrossRefGoogle Scholar
  14. 14.
    Hill C, El Zein M, Agnihotri A, et al. Endoscopic sleeve gastroplasty: the learning curve. Endosc Int Open. 2017;5:E900–4.CrossRefGoogle Scholar
  15. 15.
    Cucchi SG, Pories WJ, MacDonald KG, et al. Gastrogastric fistulas. A complication of divided gastric bypass surgery. Ann Surg. 1995;221:387–91.CrossRefGoogle Scholar
  16. 16.
    Gumbs AA, Duffy AJ, Bell RL. Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006;2:117–21.CrossRefGoogle Scholar
  17. 17.
    Chahine E, Kassir R, Dirani M, et al. Surgical management of gastrogastric fistula after Roux-en-Y Gastric Bypass: 10-year experience. Obes Surg. 2018;28:939–44.CrossRefGoogle Scholar
  18. 18.
    Felsher J, Farres H, Chand B, et al. Mucosal apposition in endoscopic suturing. Gastrointest Endosc. 2003;58:867–70.CrossRefGoogle Scholar
  19. 19.
    Fernandez-Esparrach G, Lautz DB, Thompson CC. Endoscopic repair of gastrogastric fistula after Roux-en-Y gastric bypass: a less-invasive approach. Surg Obes Relat Dis. 2010;6:282–8.CrossRefGoogle Scholar
  20. 20.
    Bhardwaj A, Cooney RN, Wehrman A, et al. Endoscopic repair of small symptomatic gastrogastric fistulas after gastric bypass surgery: a single center experience. Obes Surg. 2010;20:1090–5.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Visceral and Bariatric SurgeryHirslanden Clinic Beau-SiteBerneSwitzerland

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