Late marginal ulcer perforation after Roux-en-Y Gastric bypass – A case report with two-step management (2024)

Abstract

Keywords: Perforated marginal ulcer, Two-step procedure, Bariatric surgery, Case report

Highlights

1. Introduction

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a safe procedure with acceptable short-term morbidity (4.4–7.9%) and reduced mortality (0.06–0.13%) over the last two decades [^1,2]. Nevertheless, complications can have a significant impact on the patients. Acid-related complications, such as marginal ulcers (MU), may be underdiagnosed and remain asymptomatic at first (approximately 28%) [³], but then develop into severe complications.

The MU is located at or near the gastrojejunostomy site. The mucosa in this area is vulnerable to contact with gastric acid [⁴]. With the rising number of LRYGB procedures being performed worldwide, the incidence of MU has increased from 0.6 to 25% [⁵]. The occurrence of early MU (<12months) was significantly higher (4–12%) compared to late MU (>12months; <1%) [³].

The treatment of MU remains controversial, with a lack of randomised studies and clear guidelines [⁶]. Early diagnosis of MU can be achieved through drug therapy with proton pump inhibitors (PPI), sucralfate, or if present, Helicobacter pylori eradication [⁶]. Modification of patient-related risk factors, especially smoking cessation and renunciations of non-steroidal anti-inflammatory drugs (NSAIDs), has shown efficacy in 68–100% of cases with a relapse rate of 8% [^{[6], [7], [8], [9]}]. Late diagnosis or the presence of severe complications usually requires endoscopy; 9–32% of MU patients require revision surgery [^9,10]. Perforation of MU is a potentially life-threatening condition with high morbidity.

MUs at the gastrojejunal anastomosis have often been described; however, only a few cases have illustrated acute perforation, and there are few reports on viable surgical management. The literature outlines three main surgical treatment options for perforated MUs: surgical repair (suture +/− omental patch +/− drainage), surgical anastomotic revision, or reversal of the gastric bypass. Nevertheless, the surgical strategy depends on the patient's general condition, timing and symptoms upon presentation, size and location of the perforation, and the surgeon's expertise.

This report aimed to demonstrate a two-step surgical procedure for treating the severe complications of perforated late MU in a patient with sepsis. To the best of our knowledge, this has not been described in the treatment of perforated late MU after LRYGB.

Our case is reported in line with the SCARE criteria [¹¹].

2. Case report

A 39-year-old active smoker (with a cumulative history of ten-pack years) without other comorbidities presented to the emergency department with acute-onset abdominal pain in the left upper quadrant. Due to severe obesity classified as World Health Organization (WHO) class III (183cm, 155kg, BMI 46.3kg/m²), he had undergone LRYGB six years prior, achieving a total weight loss of 51.6% by the time of presentation (currently weighing 75kg, with a BMI of 22.4kg/m²). However, no complications had been reported thus far. The patient denied taking any medications. He had missed bariatric follow-up appointments due to a change in residence. His surgical history included appendectomy and laparoscopic cholecystectomy ten years prior the patient underwent LRYGB.

Laboratory tests showed an increase in leucocytes (13G/l), no electrolyte shift, and low protein (63g/l) and albumin (36.9g/l) values. Computed tomography showed a jejunal change in calibre and ascites (Fig. 1). A bariatric surgeon decided to undergo an emergency laparoscopy.

Laparoscopic exploration excluded an obstructive cause but revealed cloudy ascites with fibrinous peritonitis, highly suggestive of perforation. Adhesions from the gastrojejunostomy were found to thicken the left lobe of the liver (Fig. 2a). Careful preparation revealed a large-volume perforated cavity covered by the liver, likely caused by a perforated MU (Fig. 2b). Due to the increasingly tricky anesthesiologic management of the patient with sepsis and extensive peritonitis, conversion to laparotomy was performed. Laparotomy revealed a vast perforated MU with an extensive cavity covered by the left lobe of the liver. Owing to the increasing requirement for vasoactive life support, the decision for discontinuity resection of the gastrojejunostomy with a remaining 8cm pouch was made. The Roux limb was sutured to the antrum to facilitate the subsequent reconstruction. A gastrotube was inserted into the gastric remnant via percutaneous gastrostomy.

Histopathology revealed chronic inflammation with sections of acute erosive inflammation but no malignancy.

The patient was discharged eight days after an uneventful postoperative course, having received seven days of intravenous antibiotic treatment (imipenem 4×500mg, day 0–day 6) and ongoing high-dose PPI therapy. Enteral feeding via percutaneous gastrostomy (Fig. 3) was initiated in accordance with the nutritional consultant's recommendations as shown in Table 1. Drinking in small sips was allowed for comfort, and a nasogastric tube was inserted preoperatively into the disconnected gastric pouch.

After optimisation of the nutritional condition, the gastrojejunostomy was laparoscopically restored nine weeks later (Fig. 4). Following an unremarkable contrast swallow examination, pureed food was permitted on postoperative day one. Enteral nutrition via the remaining gastric tube in the gastric remnant was continued for ten days postoperatively. The patient was discharged four days after the operation. Three weeks after the reconstructive surgery, the patient was in excellent condition. Therapy with a low-dose PPI, smoking cessation, and renunciations of NSAIDs were pronounced lifetime recommendations.

3. Discussion

Patients with perforated MU or massive bleeding require surgical revision and should undergo surgery performed by a specialist bariatric surgeon to improve outcomes [^6,12].

Carr et al. [⁶] reviewed the available literature and developed an algorithm for managing MU after LRYGB. As the majority of MU is located distal to the gastrojejunostomy on the antimesenteric border of the small bowel, they are often accessible for laparoscopic closure or patch repair, which is reported as the optimal treatment for perforated MU with low mortality and morbidity, postoperative pain, hospital stay, and return to work [⁶]. The new creation of gastrojejunostomy results in longer operating time, higher blood loss, and longer length of stay, and should be reserved for non-emergency surgery [¹³].

In 2018, Altieri et al. [¹⁴] published the most extensive retrospective multicentre case series involving 292 patients who developed perforated MUs; with 179 receiving surgical treatment. Among them, 115 patients underwent anastomotic repair using sutures and omental patches, while 64 underwent anastomotic revision. Anastomotic repair resulted in a shorter operation time, reduced hospital stay and lower morbidity. Although technically challenging, anastomotic revision eliminates the ulcer and provides the benefit of a new anastomosis. However, a more aggressive surgical approach does not reduce the incidence of MU recurrence.

Only two cases have described gastric bypass reversal. Fan et al. [¹⁵] described a MU that perforated the liver, and gastric bypass reversal was performed as requested by the patient. In 2017, Wang et al. [¹⁶] performed gastric bypass reversal for a giant perforated recurrent MU following anastomotic revision.

None of these recommended treatment options were possible in our case without an increased risk of morbidity or mortality. Our intraoperative findings of a wide-perforated MU, combined with increasing circulatory instability and sepsis, forced us to convert to laparotomy. Closure and omental patch repair as the gold standard treatment for perforated MU was not feasible in this particular case because of the wide perforation, adherence to neighbouring organs, massive tissue induration, and critical condition of the patient. Considering anastomotic revision, we had reasonable concerns about anastomotic healing because of our patient's severe condition, marked by fulminant sepsis, an increasing need for catecholamines, peritonitis, and poor nutritional status, which were the main risk factors for anastomotic leakage. Furthermore, given the patient's deteriorating condition, we aimed to minimize the duration of surgery. During preoperative discussions regarding the possibility of gastric bypass reversal, the patient declined this option due to concerns of weight regain and subsequent decline of quality of life. Furthermore, this procedure is not feasible for patients with septic emergencies.

Comparable situations in non-bariatric surgery with hollow organ perforation and contamination of the situs in an unstable patient are managed by damage-control surgery using a two-step procedure. First, the perforation site is resected and the intestinal tract proximal to the perforation is either closed or diverted. After stabilisation, the continuity of the intestinal tract is restored. The transfer of a visceral surgical procedure according to the particular requirements of bariatric surgery and its patients was the only feasible surgical option for quickly stabilising our patient and counteracting inflammation. Sufficient enteral nutrition needed to be ensured after discontinuous resection. A gastrotube was inserted into the gastric remnant via percutaneous gastrostomy. After patient stabilisation and improvement in nutritional status, the second step was to create a new gastrojejunostomy with a lower risk of anastomotic leakage.

An experienced bariatric surgeon performed both surgeries. To the best of our knowledge, this is the first documented two-step procedure successfully performed for perforated MU in a critically ill patient.

4. Conclusion

A two-step procedure, as demonstrated in our case, involving discontinuity resection as damage control surgery followed by patient stabilisation and improvement of nutritional status, followed by elective continuity restoration with a new gastrojejunostomy, is considered feasible in critically ill patients.

Informed consent

Written informed consent was obtained from the patient to ensure access to his medical records. The patient's identity is protected.

Ethical approval

Ethical approval for this report is optional considering the nature of the study.

Funding

This study did not receive any specific grants from public, commercial, or nonprofit funding agencies.

Author contribution

NP: Literature search, manuscript draft.

LCV: critical revision of the manuscript.

TS: concept of presentation, critical revision of the manuscript.

PF: idea, writing support, data gathering.

Guarantor

Nina Pfeifer is the corresponding author of this article.

Research registration number

Not applicable.

Conflict of interest statement

The authors declare no conflict of interest.

Acknowledgements

None.

References