Laparoscopic gastric pouch and remnant resection: a novel approach to refractory anastomotic ulcers after Roux-en-Y Gastric Bypass: Case report

We herein report a case of an insidious marginal ulcer refractory to both medical therapy with high-dosed proton pump inhibitors and sucralfate as well as surgical therapy consisting of the lengthening of a short alimentary limb and later resection of the gastroenterostomy and construction of a new tension-free anastomosis. Only after gastrectomy by laparoscopic en-bloc resection of the gastrojejunostomy, the gastric pouch and resection of the gastric remnant with reconstruction by esophagojejunostomy the patient remained free of symptoms.By laparoscopic resection of the entire gastric pouch and the gastric remnant the risk to leave a suboptimally vascularised or even ischemic pouch in situ was avoided. The esophagojejunostomy was then created in healthy, good vascularised tissue. In our case this novel approach was effective in the management of a refractory anastomotic ulcer and might represent a rescue option when simple revision of the gastrojejunostomy fails.A specific complication after laparoscopic Roux-en-Y-Gastric-Bypass (LRYGB) is a marginal or anastomotic ulcer (AU) occurring at the gastrojejunal anastomosis. While AU can remain asymptomatic in 62-92% of the cases [1-4], they can frequently cause disabling pain or complications such as perforation and bleeding [5,6]. The incidence of AU varies from 0.6% to 16% in endoscopic studies [1-4].The etiology of AU is unclear. Two classes of risk factors have been suggested: operative and patient related factors. Although large gastric pouch, vertically oriented pouch [7], gastro-gastric fistula [8], local tissue ischemia due to anastomotic tension [9] or presence of foreign bodies in the ulcer ground (e.g. nonabsorbable sutures) [10] have been previously discussed, there is still a lack of high level of evidence demonstrating these factors to be significant. In contrast, better data exist for patient related factors, showing that smoking (odds ratio (OR) 30.6), use of nonsteroidal anti-inflammatory drugs (OR 11.5