Gastric remanent perforation after Roux-en-Y gastric bypass

Abstract text (incl. references and figure legends)

Case history: A 40-year-old female patient with a past medical history of morbid obesity treated in 2021 with RYGB, weight loss 60 kg in a year (prior to RYGB her BMI measured 45 kg/m2 and now 28 kg/m2). Preoperative gastroscopy esting H. pylori was negative. She presented to our emergency department with a diffuse abdominal pain that started suddenly and located in epigastric and mesogastric region without any fever.
Clinical findings showed a normofrequent, normotensive afebrile patient with diffuse abdominal tenderness and rebound. Laboratory results were leukocytosis and neutrofilia. The computed tomography (CT) of the abdomen showed suspicions of a perforated pyloric ulcer. A diagnostic laparoscopy was performed. It showed a widespread infectious peritonitis and two gastroentero anastomosis perforations as chronic ulcers. Surgery was performed with a primary closure with Graham epiploplasty. She had an unremarkable post-operative course, and she was discharge on the 6th postoperative day. Comments: Bariatric surgery has been the most effective way of long-lasting weight loss. Regarding the safety and efficacy of bariatric surgery, it has a lower all-cause mortality compared to nonsurgical care. However, surgical complications of RYGB don"t go unnoticed: internal hernia (6%), anastomotic stenosis (12%), gastric erosion (7%) and intestinal obstruction (5%) are longer-term complications.Gastric remnant perforation after RYGB is rare complication. Several mechanisms have been proposed to explain it such as H. Pylori infection (prevalence of 53% among bariatric patients). Also, it"s well known that acid produced in the gastric remnant may remain unneutralised. Early diagnosis is crucial in post bariatric emergencies. A CT scan may provide valuable information in treatment planning, time is important for morbidity and mortality in peptic ulcer perforation. References: doi: 10.1007/s11695-020-04537-w, doi: 10.1308/rcsann.2018.0216.

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