Gastrocutaneous fistula after gastric bypass is a rare complication. Causes include iatrogenic, traumatic or inflammatory etiologies. Pain and wound complications are debilitating. Multiple approaches exist including percutaneous, endoscopic, and surgical options. Endoscopic approaches involve clipping and fistula plugs and stenting to seal and exclude the fistula.
We present a case of a 75-year-old woman with a history of open non-divided gastric bypass 19 years prior that presented with a chronic draining intercostal wound. This started after a thoracoscopic lung and rib resection that was complicated by an infected wound requiring debridement. Surgical history includes splenectomy, abdominoplasty, and ventral herniorrhaphy. The diagnosis was confirmed by fistulogram, which revealed filling of the excluded stomach. Endoscopic approach was not feasible due to the location. Despite multiple abdominal surgeries, a minimally invasive approach was feasible. Access was gained via optical trocar insertion into the right upper quadrant. Additional access ports were placed in the right flank. Extensive adhesive disease was encountered and dissected sharply. The fistula was identified in the left upper quadrant and with great care the tract was dissected circumferentially and sharply divided. The portion of the excluded stomach with the fistula was resected with a linear stapler. The overlying abdominal wall was debrided and packed.
The patient had a normal upper GI and was discharged home with local wound care after tolerating a diet on post-operative day 4.
A minimally invasive surgical approach is feasible to manage chronic gastrocutaneous fistula in the setting of multiple prior surgeries.