Laparoscopic management of a perforated ulcer at the gastrojejunal anastomosis after LGBP

  • Abstract
    Anastomotic ulcers (also known as ‘‘marginal’’ ulcers) develop as a complication of Roux-en-Y gastric bypass for treatment of obesity, they are almost always found to arise in the jejunal Roux limb directly abutting the gastrojejunal anastomosis. Marginal ulcers have been reported in 1–16% of patients after gastric bypass surgery, developing in both the early and late postoperative periods. Recommended references: 1. Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–516. 2. Csendes A, Burgos AM, Altuve J, Bonacic S. Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg 2009;19:135–138. 3. Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009;5:317–322. 4. St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668. 5. Goitein D. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;13(6):880–882.
  • 00'18" Introduction
    This is the case of a 32 year-old woman who was admitted to the hospital\'s emergency department because of sudden onset abdominal pain, 3 years after a laparoscopic gastric bypass. The physical exam revealed muscular defense at the upper abdominal quadrants. The abdominopelvic CT-scan detected a massive pneumoperitoneum. Decision was made to bring the patient to the OR for an exploratory laparoscopy. The patient was placed supine in the Lloyd-Davis position. The optical port was introduced at the midline, at the level of the previous incision using the open Hasson’s technique.
  • 00'58" Abdominal cavity exploration
    The exploration of the abdominal cavity revealed a fluid collection originating from the upper digestive tract as well as pseudo-membranes.
  • 01'11" Identification of perforated ulcer
    Further exploration allowed to identify a jejunal perforated ulcer at the level of the gastrojejunal anastomosis.
  • 01'20" General management
    Marginal ulceration is a challenging problem, which can cause significant morbidity in the postoperative bariatric patient. Marginal ulcers develop typically on the jejunal side. The documented incidence of marginal ulcers is quite variable, ranging from 0.6 to 16 percent. The true incidence is very likely much higher than reported, since documented ulcers represent only those that are identified on endoscopy and many may be treated medically based on symptoms without ever undergoing an endoscopic evaluation. While the exact etiology of marginal ulcers remains obscure, some mechanisms have been postulated. Non-steroidal anti-inflammatory drugs (NSAIDS) lead to mucosal damage. Smoking causes mucosal ischemia, and foreign bodies (suture or staples) can lead to mucosal breakdown and ulceration. A high acid milieu can arise from a dilated gastric reservoir or, in the setting of a gastro-gastric fistula, the acid produced in the gastric remnant can reflux into the gastric pouch via the fistula and break down the mucosal integrity.
  • 02'35" Ulcer suturing
    The ulcer was sutured using an absorbable braided 2/0 thread. The jejunum just distal to the gastrojejunal anastomosis is bathed in this acid and, given that it does not have the acid buffering capability of the duodenum, it becomes vulnerable to ulcer formation. In addition, while prevention is key, it is often difficult to achieve. While most of these types of ulcers do respond to medical therapy, there is a select group of patients that continues to suffer from symptomatic, non-healing ulcers, despite appropriate medical treatment, and requires surgical intervention. For perforated marginal ulcer, diagnostic laparoscopy with repair has been found to be safe and successful, particularly in the first 24 hours of diagnosis and for patients without evidence of sepsis or hemodynamic instability. The first step is to perform a thorough investigation by mobilizing the remnant stomach, duodenum, and Roux limb to identify the source of perforation. Once identified, repair is performed by oversewing the perforation. Others advocate primary closure with absorbable suture, reinforcement with a gastrosplenic ligament patch and fibrin sealant, and closed-suction drain placement. If laparoscopic repair cannot be performed safely, the operative plan should be carried out in an open fashion. If primary closure is not possible, irrigation and drainage is the next appropriate approach. If ischemia is suspected as the cause of the perforated marginal ulcer, then complete reconstruction of the gastrojejunostomy is indicated.
  • 04'35" Omentoplasty
    The omentoplasty was carried out. The collection was drained. A nasogastric tube was placed under vision by the anesthesiologist. A drain was left in place next to the suture. The postoperative period was uneventful. The patient was kept NPO for 5 days. The gastrografin swallow on the postoperative day 5 was normal. The patient resumed food intake progressively from postoperative day 5 onwards without any problem, and the drain was removed at postoperative day 5.
  • Related medias
    Anastomotic ulcers (also known as ‘‘marginal’’ ulcers) develop as a complication of Roux-en-Y gastric bypass for treatment of obesity, they are almost always found to arise in the jejunal Roux limb directly abutting the gastrojejunal anastomosis. Marginal ulcers have been reported in 1–16% of patients after gastric bypass surgery, developing in both the early and late postoperative periods. Recommended references: 1. Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–516. 2. Csendes A, Burgos AM, Altuve J, Bonacic S. Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg 2009;19:135–138. 3. Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009;5:317–322. 4. St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668. 5. Goitein D. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;13(6):880–882.