Background

This video presentation is of a laparoscopic takedown of gastro-gastric fistula, gastro-colic fistula and revision of Roux-en-Y gastric bypass (RYGB) in a 33 year-old female with severe malnutrition and BMI of 18.2 with history of sleeve gastrectomy (SG) to RYGB for gastroesophageal reflux disease after SG at an outside hospital. She presented with severe protein calorie malnutrition, failure to thrive, liver failure and pulmonary embolism necessitating admission to the intensive care unit. Her SG to RYGB was complicated by a marginal ulcer that required revision of the gastrojejunostomy at the same facility. At the initial consultation, workup showed a gastro-gastric fistula, gastro-colic fistula, recurrent gastrojejunostomy stenosis, ascites and anasarca. For nutritional and medical optimization, a percutaneous endoscopic jejunostomy (PEJ) tube was placed into the Roux limb. Once optimization was achieved, she underwent laparoscopic exploration with takedown of gastro-gastric fistula, gastro-colic fistula, removal of PEJ tube from the Roux limb and revision of the jejuno-jejunostomy and lengthening of the Roux limb from 20 to 80cm and revision of gastrojejunal anastomosis utilizing a hand-sewn technique with absorbable monofilament suture. Post-operatively, she was started on a liquid diet. She was discharged on post-operative day 1. In follow up, she was tolerating a liquid diet and gaining weight. She was. Placed on low molecular weight heparin for 4 weeks due to history of pulmonary embolism. Conclusion: Re-revisional bariatric surgery is safe to be performed laparoscopically and our preferred method for revision of a gastrojejunostomy is in a two-layered handsewn technique with absorbable monofilament suture.