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Munhoz A, Paiva C, Mesquita I, Correia T, Marcos M, Santos J, Soares P. Perforated duodenal ulcer after Roux-en-Y gastric bypass: an unusual complication. Endocrinol Diabetes Metab Case Rep 2024; 2024:24-0049. [PMID: 39007518 DOI: 10.1530/edm-24-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 06/19/2024] [Indexed: 07/16/2024] Open
Abstract
Summary Bariatric surgery is increasingly being accepted as a viable treatment for managing the growing obesity epidemic. Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures. Perforated duodenal ulcer following RYGB is a rare condition with a low incidence. We report a case of a patient with a perforated duodenal ulcer post RYGB, and the surgical approach. A 66-year-old man with hypertension and a history of laparoscopic RYGB for class III obesity was admitted to the emergency department with severe epigastric pain radiating to the right side of his abdomen and right shoulder, associated with nausea and vomiting. Computed tomography (CT) showed intraperitoneal free fluid, a thickened wall of the duodenum and free air, duodenal perforation was suspected. The patient underwent exploratory laparoscopy that revealed a perforated duodenal ulcer that was closed with an absorbable barbed suture and omental patch. Perforated ulcers in excluded segments after RYGB are a rare entity with a challenging diagnosis, and clinicians should be aware of and have a low threshold for diagnostic laparoscopy. Learning points Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures in bariatric surgery. Perforated ulcers in excluded segments after RYGB are a rare entity with a challenging diagnosis. The pathophysiology of this perforation is not clear, but several mechanisms have been proposed. Helicobacter pylori has been implicated. Clinicians should be aware and have a low threshold for diagnostic laparoscopy for a patient who has acute abdominal pain after RYGB, despite negative diagnostic measures.
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Affiliation(s)
- Ana Munhoz
- Unidade Local de Saúde de Santo António - ULSSA, Porto, Portugal
- Department of Digestive and Extra-Digestive Surgery, Porto, Portugal
| | - Cláudia Paiva
- Unidade Local de Saúde de Santo António - ULSSA, Porto, Portugal
- Department of Digestive and Extra-Digestive Surgery, Porto, Portugal
| | - Isabel Mesquita
- Unidade Local de Saúde de Santo António - ULSSA, Porto, Portugal
- Department of Digestive and Extra-Digestive Surgery, Porto, Portugal
- Obesity Treatment Center - Unidade de Tratamento Cirúrgico de Obesidade (UTCO), Porto, Portugal
- CAC ICBAS-CHP, Porto, Portugal
- I3S, Glycobiology and Cancer Research, Porto, Portugal
| | - Teresa Correia
- Unidade Local de Saúde de Santo António - ULSSA, Porto, Portugal
- Department of Digestive and Extra-Digestive Surgery, Porto, Portugal
- Obesity Treatment Center - Unidade de Tratamento Cirúrgico de Obesidade (UTCO), Porto, Portugal
| | - Mário Marcos
- Unidade Local de Saúde de Santo António - ULSSA, Porto, Portugal
- Department of Digestive and Extra-Digestive Surgery, Porto, Portugal
- Obesity Treatment Center - Unidade de Tratamento Cirúrgico de Obesidade (UTCO), Porto, Portugal
| | - Jorge Santos
- Unidade Local de Saúde de Santo António - ULSSA, Porto, Portugal
- Department of Digestive and Extra-Digestive Surgery, Porto, Portugal
- Obesity Treatment Center - Unidade de Tratamento Cirúrgico de Obesidade (UTCO), Porto, Portugal
| | - Paulo Soares
- Unidade Local de Saúde de Santo António - ULSSA, Porto, Portugal
- Department of Digestive and Extra-Digestive Surgery, Porto, Portugal
- Obesity Treatment Center - Unidade de Tratamento Cirúrgico de Obesidade (UTCO), Porto, Portugal
- CAC ICBAS-CHP, Porto, Portugal
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Hughes L, Morris M, Que B, Rai G, Jorge J, Tiesenga F. Perforated Duodenal Ulcer Post-Roux-en-Y Gastric Bypass: A Case Report. Cureus 2023; 15:e35112. [PMID: 36945278 PMCID: PMC10024948 DOI: 10.7759/cureus.35112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 02/19/2023] Open
Abstract
Obesity is a growing health concern worldwide, with bariatric surgeries such as gastric bypass providing an effective treatment choice. However, a rare complication of gastric bypass is a duodenal ulcer. Currently, there is no exact incidence of this complication, and only a few case reports have been published in the literature. Presented is a case of a 32-year-old patient, eight years status post gastric bypass, who was evaluated for surgical repair of a large anterior perforated duodenal ulcer. This case report explores the relationship between patient history and gastric bypass surgery in the case of duodenal ulcer formation and perforation, as well as the diagnostic difficulty and modalities for duodenal ulcers in post-gastric bypass patients.
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Affiliation(s)
- Lauren Hughes
- Medical School, Saint James School of Medicine - Anguilla Campus, The Quarter, AIA
- General Surgery, West Suburban Hospital Center, Oak Park, USA
| | | | - Bryton Que
- Medical School, Saint James School of Medicine - Anguilla Campus, The Quarter, AIA
| | - Geetan Rai
- Surgery, Avalon University School of Medicine, Chicago, USA
| | - Juaquito Jorge
- General and Bariatric Surgery, West Suburban Hospital, Oak Park, USA
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Bile Leak following Laparoscopic Cholecystectomy due to Perforated Duodenal Ulcer in Patient with Roux-en-Y Gastric Bypass. Case Rep Surg 2021; 2021:6662433. [PMID: 34395015 PMCID: PMC8357508 DOI: 10.1155/2021/6662433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/26/2021] [Indexed: 11/17/2022] Open
Abstract
Perforated ulcers of the excluded stomach or duodenum are exceedingly rare in patients who have undergone Roux-en-Y gastric bypass surgery. The diagnosis of perforated ulcer after Roux-en-Y gastric bypass remains challenging as there is often absence of free air or contrast extravasation from the biliopancreatic limb. We present a patient with signs and symptoms of acute cholecystitis. Laparoscopic cholecystectomy was complicated by postoperative bile leak. EDGE procedure was performed to access the remnant stomach and endoscopic evaluation revealed a perforated ulcer in the posterior duodenal bulb. Although unusual, in patients with bariatric surgery and upper abdominal pain, differential diagnosis including perforated ulcer of the biliopancreatic limb must be considered and early surgical exploration is essential.
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Ulcer Disease in the Excluded Segments after Roux-en-Y Gastric Bypass: a Current Review of the Literature. Obes Surg 2020; 31:1280-1289. [PMID: 33230760 PMCID: PMC7921036 DOI: 10.1007/s11695-020-05123-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 02/08/2023]
Abstract
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.
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Zarrin A, Sorathia S, Choksi V, Kaplan SR, Kasmin F. Endoscopic approach to gastric remnant outlet obstruction after gastric bypass: A case report. World J Gastrointest Endosc 2020; 12:297-303. [PMID: 32994860 PMCID: PMC7503611 DOI: 10.4253/wjge.v12.i9.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/04/2020] [Accepted: 08/16/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Arash Zarrin
- Department of Internal Medicine, Aventura Hospital and Medical Center, Miami, FL 33180, United States
| | - Sufian Sorathia
- Department of Gastroenterology, Aventura Hospital and Medical Center, Miami, FL 33180, United States
| | - Vivek Choksi
- Department of Gastroenterology, Aventura Hospital and Medical Center, Miami, FL 33180, United States
| | - Steven Robert Kaplan
- Department of Gastroenterology, Aventura Hospital and Medical Center, Miami, FL 33180, United States
| | - Franklin Kasmin
- Department of Gastroenterology, Aventura Hospital and Medical Center, Miami, FL 33180, United States
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Perduca P, Waisberg DR, Pinheiro RSN, Hourneaux-DE-Moura EG, D'Albuquerque LAC, Andraus W. A POSSIBLE COMPLICATION AFTER LIVER TRANSPLANTATION IN A GASTRIC BYPASS BARIATRIC PATIENT: DON'T FORGET THE EXCLUDED STOMACH! CASE REPORT AND REVIEW OF THE LITERATURE. ACTA ACUST UNITED AC 2020; 33:e1510. [PMID: 32844879 PMCID: PMC7448854 DOI: 10.1590/0102-672020190001e1510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/18/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | - Daniel Reis Waisberg
- Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Wellington Andraus
- Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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Dai L, Shah MM, Rosenblatt S. Perforated gastric remnant ulcer after laparoscopic gastric bypass. BMJ Case Rep 2018; 2018:bcr-2017-222190. [PMID: 29622702 DOI: 10.1136/bcr-2017-222190] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Lu Dai
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Mihir M Shah
- Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Steven Rosenblatt
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Hakim S, Reddy SRR, Batke M, Polidori G, Cappell MS. Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy. World J Gastrointest Endosc 2017; 9:521-528. [PMID: 29085563 PMCID: PMC5648995 DOI: 10.4253/wjge.v9.i10.521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/04/2017] [Accepted: 06/13/2017] [Indexed: 02/05/2023] Open
Abstract
The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy (EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass (RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status post RYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.
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Affiliation(s)
- Seifeldin Hakim
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Srinivas R Rami Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Mihaela Batke
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Gregg Polidori
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Mitchell S Cappell
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, MI 48073, United States
- Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
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Zaveri H, Dallal RM, Cottam D, Surve A, Kartiko S, Bonnani F, Cottam A, Cottam S. Indications and Operative Outcomes of Gastric Bypass Reversal. Obes Surg 2017; 26:2285-90. [PMID: 26883929 DOI: 10.1007/s11695-016-2105-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is one of the best-known and most commonly performed bariatric procedures. However, this procedure carries infrequent but serious long-term complications, which may require revisional procedures. This study reports the indications and outcomes of gastric bypass reversal that have not been described well in the literature. METHODS A multicenter retrospective study of 50 patients who underwent reversal of RYGB conducted between 2006 and 2015 was reviewed to describe the usual indications and outcomes of gastric bypass reversal surgeries. RESULTS Of 50 patients, 7 (14 %) were males and 43 (86 %) were females. The mean age of the patient population was 40.4 ± 11.6 years (range 19-66). Reasons for reversal included anastomotic ulcers (n = 27), anastomotic complications (n = 9), malnutrition (n = 2), and functional disorder (n = 12). The mean BMI before the reversal was 29 ± 9.4 kg/m(2) (range 16-60). The mean time between the primary procedure and reversal was 60 ± 65.5 months (range 2-300). Fourteen of the reversals were done via laparotomy. Mean hospital stay was 8.4 ± 7.3 days (range 3-34 days). There was no peri-operative death 30 days after reversal. Following gastric bypass reversal, 92.6 % (n = 25) of the patient population had resolution from ulcers, 77.8 % (n = 7) of the patient population had resolution from anatomic complications, 100 % (n = 2) of the patient population had resolution from malnutrition, and 66.7 % (n = 8) of the patient population had resolution from functional disorders. CONCLUSIONS Gastric bypass reversal is a reasonable and safe treatment for complications arising from the GBP surgery. A laparoscopic approach is feasible in select patients.
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Affiliation(s)
- Hinali Zaveri
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Ramsey M Dallal
- Einstein Healthcare Network, 60 Township Line Road, Elkins Park, PA, 19027, USA
| | - Daniel Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA.
| | - Amit Surve
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Susan Kartiko
- Einstein Healthcare Network, 60 Township Line Road, Elkins Park, PA, 19027, USA
| | - Fernando Bonnani
- Abington Memorial Hospital, 225 Newtown Rd, 2nd Flr-Main Bldg, Warminster, PA, 18974, USA
| | - Austin Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Samuel Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
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