In a 50 year male patient with a BMI of 45 kg/m2 an antecolic, antegastric LRYGB with a 100 cm alimentary and a 60 cm biliary limb was performed. The gastrojejunostomy was constructed using a 25 mm circular stapler (EEA 2535, 3.5 mm Staples, Covidien®). Simultaneously, a 6 cm silastic (Fobi) ring was placed around the gastrojejunostomy. A few weeks after discharge, the patient, who continued smoking after surgery, presented with strong epigastric pain, postprandial regurgitation and vomiting. He was unable to eat solid food and to attend work. Endoscopy revealed two AU at the gastrojejunostomy. Oral PPI therapy (esomeprazole, 80 mg/die) was initiated and, since it was thought to be partly responsible for the symptoms, the silastic ring was removed. Intravenous high-dose PPI (esomeprazole, 240 mg/die) led to healing of the AU. However, epigastric pain and regurgitation did not ameliorate. A 99 m Tc-mebrofenin scintigraphy revealed severe biliary reflux. Seven months after LRYGB the patient was referred to our department.
At the initial consultation the patient was taking up to 600 mg/day esomeprazole and 200 mg/day tilidin orally. As an AU could not be detected further diagnostic investigations were performed:
• Upper gastrointestinal (GI) contrast series revealing a small gastric pouch without signs of a gastric fistula and normal passage.
• Double balloon push enteroscopy demonstrating a short (40 cm) alimentary limb.
• High-resolution esophageal manometry revealing a normotensive propulsive peristalsis and a normotense lower esophageal sphincter.
• 24 h-impedance pH-metry - performed under antacid medication - showing no pathological acid or non-acid reflux.
• MRI in Sellink technique showing no obstruction of the small bowel.
Apart from the biliary reflux diagnosed by scintigraphy consistent with a very short Roux-limb by push-enteroscopy, no other reason for the epigastric pain was detected. We performed a laparoscopic lengthening of the Roux limb by additional 120 cm resulting in a new alimentary limb of 160 cm. Oral PPI therapy (80 mg/day) was continued and sucralfate (4 g/d) was added.
After a short period without pain and regurgitation, symptoms recurred two weeks after Roux limb lengthening. Despite PPI therapy endoscopy revealed a recurrent AU at the gastrojejunostomy (Figure ). Therefore a laparoscopic resection of the gastrojejunostomy was performed followed by a construction of a new, tension-free anastomosis using a 25 mm circular stapler (EEA 2535, 3.5 mm Staples, Covidien®). PPI therapy and sucralfate were continued. Again the patient was discharged free of symptoms on postoperative day five.
Recurrent anastomotic ulcer in the intestinal part of the gastrojejunostomy.
One month later and one year after initial LRYGB surgery, the patient was again not free of epigastric pain. Gastroscopy showed again a large AU at the gastroenterostomy. Meanwhile, the patient was finally motivated enough to quit smoking and was enrolled in a stop-smoking program. Since gastrin level was not elevated (111 ng/l) an underlying gastrinoma could be excluded. Furthermore, Helicobacter pylori and hyperparathyroidism as additional potential causes for anastomotic ulcers were also ruled out. Nevertheless, epigastric pain and the AU persisted.
At this point an aggressive approach was decided consisting of a gastrectomy by laparoscopic en-bloc resection of the gastrojejunostomy and the gastric pouch with transsection 2 cm proximal to the angle of His and resection of the gastric remnant (Figure ). The gastrointestinal continuity was re-established by the construction of an esophagojejunostomy using a 25 mm circular stapler (Figure ). Two days after surgery an upper GI contrast series showed no leakage or stenosis at the level of the esophagojejunostomy. The patient was discharged on postoperative day 10. Six months later the patient was free of symptoms, he was able to start opioid weaning and had regained 6 kg of weight. Finally, endoscopy showed a regular esophagojejunostomy.
Situs after en-bloc resection of the gastric pouch and the gastrojejunostomy. (1 = esophagus, 2 = hepatoduodenal ligament, 3 = caudate lobe).
Roux-Y reconstruction with esophagojejunostomy.