Gastrojejunocolic fistula: case report of a rare late complication of laparoscopic Roux-en-Y gastric bypass and review of the literature.

INTRODUCTION: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is known as the weight loss surgery to which other bariatric procedures are compared. While morbidity and mortality of this procedure are low, serious complications do exist which can be life-threatening and sometimes require surgical correction. CASE PRESENTATION: A 63-year-old woman underwent LRYGB outside of the United States, later complicated by biliary colic treated with cholecystectomy and upper gastrointestinal bleeding secondary to H. pylori-related ulcer at her gastrojejunostomy. Following adequate treatment of the patients marginal ulcer, the patient experienced several months of progressive severe abdominal pain, frequent vomiting and diarrhea, and unintentional weight loss refractory to pharmacologic therapy. The patient underwent multiple medical and endoscopic evaluations unrevealing of an organic cause of her symptoms. At presentation, the patient was found to be profoundly weak, dehydrated and malnourished with metabolic derangements and was subsequently diagnosed with a gastrojejunocolic fistula via upper endoscopy and radiography. We provided excluded stomach gastrostomy tube feeding to the patient for three months to improve the patients nutritional status before definitive surgical correction was successfully performed. DISCUSSION: Large bowel fistulas are a rare and highly morbid late complication following LRYGB and are likely secondary to marginal ulcers and/or instrumentation such as endoscopy. Surgery represents the definitive treatment. CONCLUSION: LRYGB is typically a safe and effective intervention for obesity. Large bowel fistulas are rare complications following this surgery. We highlight difficulties in diagnosing and treating this condition.

Salvage cryotherapy in patients undergoing endoscopic eradication therapy for complicated Barrett's esophagus.

Background and study aims Some patients with dysplastic Barrett's esophagus (BE) experience suboptimal response to radiofrequency ablation (RFA), endoscopic mucosal resection (EMR), or the combination. Cryotherapy has been used as salvage therapy in these patients, but outcomes data are limited. We aimed to assess clinical outcomes among a large cohort of patients with dysplastic BE whose condition had failed to respond to RFA and/or EMR. Patients and methods This was a retrospective cohort study of consecutive cases of dysplastic BE or intramucosal carcinoma (IMC) treated with salvage cryotherapy at a tertiary-care academic medical center. The primary goal of cryotherapy treatment was eradication of all neoplasia. The secondary goal was eradication of all intestinal metaplasia. The proportion of patients undergoing salvage cryotherapy who achieved complete eradication of dysplasia (CE-D) and metaplasia (CE-IM), as well as the time to CE-D and CE-IM were calculated. Results Over a 12-year period, 46 patients received salvage cryotherapy. All patients underwent RFA prior to cryotherapy, either at our center or prior to referral, and 50 % of patients underwent EMR. A majority of patients (54 %) had high-grade dysplasia (HGD) at referral, while 33 % had low-grade dysplasia (LGD), and 13 % had IMC. Overall, 38 patients (83 %) reached CE-D and 21 (46 %) reached CE-IM. Median time to CE-D was 18 months, median number of total interventions (RFA, cryotherapy, and EMR) was five, and median number of cryotherapy sessions was two. Conclusion Salvage cryotherapy appears safe and effective for treating BE that is refractory to RFA and/or EMR.