Surgical Management of Recurrent Gastrojejunocolic Fistula With Gastric Antrectomy and Bilateral Vagotomy

Gastrojejunocolic fistulas (GJCFs) are rare complications following gastrojejunostomy and Roux-en-Y procedures, most often in the context of peptic ulcer disease.

A 42-year-old woman, with a history of cocaine addiction, underwent an gastrojejunostomy, a transgastric closure of the gastric pylorus, and a Graham patch for a perforated duodenal ulcer. She then presented with a dehisced gastrojejunal anastomosis. Resection of the dehisced anastomosis and Roux-en-Y reconstruction was performed. Eight months later, the patient returned to the hospital with a GJCF. A one-stage en-bloc GJCF resection with redo Roux-en-Y was performed. Six months later, a scan demonstrated a recurrent GJCF. Antrectomy and bilateral truncal vagotomy were performed to avoid recurrent gastric acid secretion. Resection of the dehisced gastrojejunal anastomosis and the segment of fistulized transverse colon was performed. A third Roux-en-Y reconstruction was fashioned. The patient evolved well and showed no signs of recurrent disease.

The cornerstone treatment of GJCF is the administration of parenteral nutrition, followed by a single-stage en-bloc procedure. Some factors that can contribute to recurrent GJCF are retained gastric antrum syndrome, incomplete vagotomy, and noncompliance with oral antacid therapy. Despite the significant leaps in the medical management of peptic ulcer disease in recent years, surgical strategies that reduce excess gastric acid secretion should be considered in select cases.

This case highlights that gastric antrectomy and bilateral vagotomy have not been rendered obsolete in the 21st century, particularly in patients who cannot be compliant with oral proton pump inhibitors.