An unusual complication of gastric bypass: perforated duodenal ulcer

Perforation of the excluded segment without pneumoperitoneum following Roux-en-Y gastric bypass surgery: case report and literature review

BACKGROUND

Because of the increasing prevalence of obesity and bariatric surgery (Roux-en-Y gastric bypass (RYGB) as the gold standard), there is a still growing population of people with altered post-operative anatomy. Although the most common early and late complications following RYGB are well known, they can still be difficult to diagnose. The altered anatomy after RYGB can create a real diagnostic and therapeutic challenge since routine examinations can be negative.

CASE REPORT

We present a rare case of a 38-year-old woman with acute abdominal pain and a history of RYGB who proved to have a duodenal perforation in the absence of free air on radiologic examination. The perforation was closed laparoscopically and proton pump inhibitors were administered.

CONCLUSIONS

Perforations of the excluded segment in RYGB patients are rare and represent a diagnostic challenge, as pneumoperitoneum is usually absent and the excluded segment is difficult to access. Despite negative diagnostic findings, laparoscopic exploration should always be considered.

Ulcer Disease in the Excluded Segments after Roux-en-Y Gastric Bypass: a Current Review of the Literature

Ulcer disease in excluded segments after Roux-Y gastric bypass (RYGB) is rare but can evolve into a life-threatening situation. The excluded segments exhibit a different behavior from that of non-altered anatomy; perforated ulcers do not result in pneumoperitoneum or free fluid, and therefore must be met with a low threshold for surgical exploration. The anatomical changes after RYGB impede routine access to the remnant stomach and duodenum. There are various options to address bleeding or perforated ulcers. While oversewing and drainage preserves the anatomy and forgoes resection, remnant gastrectomy offers a definitive solution. The importance of traditional risk factors such as smoking or use of non-steroidal anti-inflammatory drugs is unclear. Eradication of Helicobacter pylori and secondary prophylaxis with proton-pump inhibitors is advisable, albeit in double-dose.

Perforated gastric remnant ulcer after laparoscopic gastric bypass

Ulcer perforation in the excluded stomach and duodenum is a rare complication after Roux-en-Y gastric bypass (RYGB). Pathogenesis of these ulcers are multifactorial. We report a case of perforated gastric remnant ulcer in a 54-year-old woman who had undergone a laparoscopic RYGB 5 years previously. The perforation was successfully repaired with an omental patch. We also present a review of the literature of similar cases.

Perforation of the gastric remnant in a patient post-Roux-en-Y gastric bypass

With the dramatic increase in obesity surgery and the subsequent increase in ageing post-gastric bypass patients, early recognition of possible and serious complications is of the utmost importance. We present a case of a 33-year-old woman who presented to the emergency room, with progressive epigastric pain. The patient had undergone laparoscopic Roux-en-Y gastric bypass surgery 14 months earlier. Diagnostic laparoscopy was performed and showed a prepyloric perforation of the gastric remnant. The defect was closed and omentoplasty was performed. The patient was put on lifelong proton pump inhibitors.

Essential bariatric emergencies for the acute care surgeon

Bariatric surgery is the most effective treatment for morbid obesity. Due to the high volume of weight loss procedures worldwide, the general surgeon will undoubtedly encounter bariatric patients in his or her practice. Liberal use of CT scans, upper endoscopy and barium swallow in this patient population is recommended. Some bariatric complications, such as marginal ulceration and dyspepsia, can be effectively treated non-operatively (e.g., proton pump inhibitors, dietary modification). Failure of conservative management is usually an indication for referral to a bariatric surgery specialist for operative re-intervention. More serious complications, such as perforated marginal ulcer, leak, or bowel obstruction, may require immediate surgical intervention. A high index of suspicion must be maintained for these complications despite "negative" radiographic studies, and diagnostic laparoscopy performed when symptoms fail to improve. Laparoscopic-assisted gastric band complications are usually approached with band deflation and referral to a bariatric surgeon. However, if acute slippage that results in gastric strangulation is suspected, the band should be removed immediately. This manuscript provides a high-level overview of all essential bariatric complications that may be encountered by the acute care surgeon.

Diagnosis and Management of Perforated Duodenal Ulcers following Roux-En-Y Gastric Bypass: A Report of Two Cases and a Review of the Literature

Perforated duodenal ulcers are rare complications seen after roux-en-Y gastric bypass (RYGP). They often present as a diagnostic dilemma as they rarely present with pneumoperitoneum on radiologic evaluation. There is no consensus as to the pathophysiology of these ulcers; however expeditious treatment is necessary. We present two patients with perforated duodenal ulcers and a distant history of RYGP who were successfully treated. Their individual surgical management is discussed as well as a literature review. We conclude that, in patients who present with acute abdominal pain and a history of RYGB, perforated ulcer needs to be very high in the differential diagnosis even in the absence of pneumoperitoneum. In these patients an early surgical exploration is paramount to help diagnose and treat these patients.

Delayed massive bleeding two years after Roux-en-Y gastric bypass

Delayed massive bleeding from an ischemic ulcer after Roux-en-Y gastric bypass is a rare and challenging event for the gastroenterologist as well as the bariatric surgeon.

Introduction:

Delayed massive bleeding from an ischemic ulcer is a complication after Roux-en-Y gastric bypass (RYGB). Ischemic ulcers that present with massive bleeding are rare and challenging for the gastroenterologist as well as the bariatric surgeon.

Case Description:

This report reviews the case of a 63-year-old man who underwent an uncomplicated laparoscopic RYGB for morbid obesity and experienced two episodes of massive hemorrhage after the procedure, almost 1 year apart.

Conclusion:

To our knowledge, there are only a few such specific cases reported. Here, we describe the treatment and outcome for such a case and present a review of the literature.

Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) is a well-established procedure to treat morbid obesity. Gastrojejunal anastomotic (GJA) ulcers can develop after surgery with subsequent perforation. Our aim was to evaluate the incidence, presentation and outcome of management of perforated GJA ulcer disease after laparoscopic RYGB.

METHODS

The database of all patients at the senior author's bariatric institutions was retrospectively reviewed. The results are presented as mean (range).

RESULTS

From April 2002 to April 2010, 1213 patients underwent laparoscopic RYGB, which included 1184 primary and 29 revision procedures. The operative mortality was .15%. Ten patients developed perforated GJA ulcers (.82%) at a mean of 13.5 (6-19) months. The patients who presented to bariatric surgeons (n = 5) were treated with laparoscopic closure and an omental patch, and those who presented to nonbariatric surgeons (n = 5) were treated with laparotomy. The morbidity and mortality rate was 30% and 10%, respectively, and the mean postoperative hospital stay for the survivors was 14 (5-44) days.

CONCLUSION

Perforated GJA ulcers can develop in 1 of 120 patients after laparoscopic RYGB and can be effectively managed by laparoscopic repair with an omental patch, if expertise is available.

Endoscopic management of common bariatric surgical complications

The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation. Endoscopists caring for these patients should become familiar with post-bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal/extra-luminal findings, and endoscopic management of common bariatric complications; this review addresses these issues. This review will discuss common presenting symptoms, luminal as well as extra-luminal findings and endoscopic management of common bariatric complications.

Fatal fulminant pancreatitis after laparoscopic gastric bypass surgery

Current widespread application of laparoscopic techniques in Roux-en-Y gastric bypass (RYGBP) is making surgical safety an increasingly important issue. We report one case that resulted in death due to postoperative fulminant acute pancreatitis after laparoscopic RYGBP was performed when this procedure was still relatively new in China. The patient was a chronically obese 19-year-old male. Weight loss medications had been ineffective, and preoperative body mass index was 40.7. Preoperative examination revealed moderate steatohepatitis. Laparoscopic RYGBP (LRYGBP) was performed. Early manifestations of clinical shock appeared 13 h after the laparoscopic surgery. A second laparoscopic examination showed small-vessel hemorrhage at the posterior wall of the jejunojejunal anastomosis, with blood clot formation resulting in Roux limb and afferent loop obstruction. Fulminant acute pancreatitis developed in the patient 18 h after the second surgery. The patient died 15 days later from systemic multiorgan insufficiency. LRYGBP (postcolon) is a technically demanding procedure for surgeons who are not experienced in this operation. In addition, surgical tolerance is reduced in morbidly obese patients. Therefore, special care should be taken during surgery, and hemostasis must be achieved at all bleeding sites. Increased perioperative surveillance allows for early detection and management of severe complications.