Marginal ulcer causing anastomotic perforation and delayed penetration following mini gastric bypass

BACKGROUND: This study presents a rare clinical case of progressive chronic ulcer of the gastrojejunoanastomosis in a young female patient who developed two classical complications, particularly perforation and penetration, within 14 months of undergoing laparoscopic mini gastric bypass. Remarkably, the medical history did not reveal any significant predictors of ulcerogenesis. The ulcer formed within the first six months after mini gastric bypass surgery when taking antisecretory drugs. There was no connection with smoking, helicobacter infection, or use of non-steroidal anti-inflammatory drugs.

CLINICAL CASE DESCRIPTION: The patient was initially subjected to laparotomy, with perforation suturing and Roux-en-Y gastrojejunostomy performed to exclude the bile reflux into the gastric pouch. The postoperative outcome (ulcer progression with a new complication — penetration — within six months) aligns with the recent literature data on the potential exaggeration of the role of biliary reflux in ulcerogenesis following mini gastric bypass. The follow-up surgery, performed laparoscopically in the presence of significant adhesion formation in the abdominal cavity, involved adhesiolysis, gastric pouch resection with anastomosis, and reconstructive Roux-en-Y gastric bypass. Clinical and endoscopic evaluations ten months after the reconstructive surgery indicates the patient’s recovery.

CONCLUSION: The value of the observation is the possibility of analyzing the effect of the primary operation, which included not only suturing of the perforated defect, but also enteroenterostomy according to Roux to divert bile from the anastomosis. The result of the operation is consistent with the literature data on the possibly exaggerated role of biliary reflux in ulcerogenesis after mini-gastroshunting, which determines the relevance of new studies to identify significant pathogenetic factors, including the length of the pouch and the method of forming a single anastomosis.