Utilizing a PEG tube to address gastrogastric fistula and biliary drainage in a post-truant by a patient We have no disclosures to report Gastrogastric fistula is a rare complication after gastric bypass surgery with an underestimated incidence rate due to lack of follow-up. It is associated with increased morbidity and mortality rates due to complications such as aspiration and weight regain, which lead to prolonged hospital stays. Management of recurrent gastrogastric fistulas, either surgical or endoscopic, is associated with poor long-term results. As such, there is limited evidence on any successful management of such condition with endoscopy. Here, we have a 62-year-old female, status post-truant by gastric bypass for obesity who presented with symptoms predominantly of aspiration. She had a history of multiple abdominal surgeries which now resulted in a persistent gastrogastric fistula. She underwent multiple endoscopic attempts with suturing and APC as well as a laparoscopic bypass revision surgery. Despite the temporary resolution, the symptoms recurred after surgery and on EGT, a gastrogastric fistula with the remnant stomach was seen. In the image, this is seen with the yellow arrow. To manage the gastrogastric fistula, a 24 French peg tube was dropped orally into the excluded part of the stomach. The peg tube bumper and the tube itself was secured at the level of the fistula using an overstitch device and sutures in a purse string fashion as shown here in the yellow arrow. This is a hand-drawn diagram illustrating the positioning of the peg bumper at the level of the fistula as well as the tube extending into the roux limb. As shown in the diagram, the peg bumper is securely anchored using sutures arranged in a purse string fashion. This technique ensured stability while also preventing accidental displacement of the bumper. The open end of the tube was then driven into the roux limb and sutured to prevent migration of the distal end of the tube. This provides an additional function facilitating the drainage of bile reflux from the excluded portion of the stomach. This approach effectively manages bile reflux while maintaining the functional positioning of the peg bumper and tube. The open tip of the peg tube was then driven with the help of a raptor as seen in the video into the roux limb to drain the bile from the excluded part of the stomach. The decision was made to reinforce the remaining tube with the help of an overstitch device to prevent migration. On day 1 post-procedure, a fluoroscopy was performed which demonstrated no evidence of a fistula. At 3 and 6 months follow-up, the patient reported no reflux and all of her other symptoms including aspiration had resolved. She has been tolerating her food well. Thus, we describe a case where we use a novel endoscopic technique for the management of refractory gastrogastric fistula using a peg tube that served a dual purpose of a plug as well as a drain in a patient status post Roux-en-Y gastric bypass surgery.

gastrogastric fistula

gastric bypass complications

endoscopic technique

bile reflux management

PEG tube intervention