Management of gastro-gastric fistula after Roux-en-Y gastric bypass: a systematic review and meta-analysis of endoscopic versus surgical outcomes.

Gastro-gastric fistula is an uncommon but clinically significant complication after Roux-en-Y gastric bypass, presenting with weight regain, epigastric pain, bile reflux, or recurrent marginal ulceration. Although multiple endoscopic and surgical techniques have been described, comparative outcome data remain limited. We conducted a systematic review and meta-analysis of studies published between 1990 and 2025 evaluating endoscopic and surgical management of gastro-gastric fistula. Seventy-six studies underwent full-text assessment for eligibility, and 9 studies were eligible for quantitative analysis (5 endoscopic series, n = 127; 4 surgical series, n = 65). Endoscopic therapy achieved durable fistula closure in 29.9% of patients, with a low major adverse event rate (1.6%). Surgical revision demonstrated 100% clinical success, with a 26.2% postoperative complication rate and no procedure-related mortality. Random-effects modeling yielded consistent pooled estimates with low statistical heterogeneity. These findings suggest that endoscopic management offers an excellent safety profile but limited long-term durability, whereas surgical revision was associated with higher rates of durable fistula closure at the cost of higher perioperative morbidity. Given the observational nature of the available evidence, these findings should be interpreted cautiously and should not be considered evidence of definitive treatment superiority. Treatment selection should, therefore, be guided by fistula characteristics, chronicity, and patient risk profile. Standardized reporting and prospective evaluation of emerging endoscopic and hybrid techniques are needed to optimize management strategies.