Pyloric stenosis after a Roux-en-Y gastric bypass: a case report

Endoscopic approach to gastric remnant outlet obstruction after gastric bypass: A case report

BACKGROUND

Acute gastric remnant bleeding is a rare complication of bariatric surgery. Furthermore, acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously. Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach. Traditionally, this necessitates surgical intervention. Recently, however, the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.

CASE SUMMARY

A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension, nausea, and melena of two days duration. His imaging illustrated a massively distended stomach. A nasogastric tube did not result in drainage of fluid or decompression of his abdomen. His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended "fluid"-filled gastric remnant. An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant. Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum. The patient underwent emergent angiography with embolization of the gastroduodenal artery. He was discharged with a stable hemoglobin level and resolution of symptoms. Healing superficial gastric ulcers were visualized on a follow-up endoscopy. Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated, and successful eradication was achieved.

CONCLUSION

This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound-directed transgastric intervention.

The Gastric Remnant in Roux-en-Y Gastric Bypass: Challenges and Possibilities

Laparoscopic Roux-en-Y gastric bypass (RYGB) is widely applied in the treatment of morbid obesity. Health personnel meeting these patients should thus be familiar with the potential clinical consequences of the modified anatomy induced by the surgery. After a RYGB, the stomach is left in situ after the closure of the upper part of the organ. This blind-ended gastric remnant may cause complications and surgical emergencies, but also opportunities for diagnostic and therapeutic intervention. The present review focuses on complications related to the gastric remnant including bleeding and acute dilatation in the early postoperative period and later adverse events such as gastroduodenal peptic disease, tumors, gastrogastric fistulas, and late dilatation. Opportunities offered by the remnant, including minimal invasive or open access for enteral nutrition, and therapeutic and diagnostic access to the bile ducts, the duodenum, and the gastric remnant, which is challenged by the modified anatomy, are discussed. Reversal of the gastric bypass and gastrointestinal reconstruction after esophageal resection have been commented on. The review aims to improve the awareness of issues related to the gastric remnant for physicians involved in the treatment and the follow-up of patients after a RYGB.