AB019. OP19 Life threatening complication in bariatric surgery: marginal ulcer perforation

Background: Bariatric surgery has become an important adjunct in battling obesity. This life-saving surgery has many proven health benefits, but there are also potential risks and complications. Marginal ulcer formation after gastric bypass surgery is a complication that can arise in the early postoperative period or many months after the operation. The incidence of free perforation of marginal ulcers after laparoscopic antecolic gastric bypass is 1.6%. Laparoscopic repair of a perforated marginal ulcer after laparoscopic or robotic gastric bypass is a feasible, safe alternative to open exploration in hemodynamically stable patients. This article discusses the surgical management and the operative technique used in 2 patients who had the laparoscopic mini gastric bypass (MGB) operation.

Methods: A 15 mmHg pneumoperitoneum was established with a Veress needle via the left subcostal approach in both patients. Entrance into the abdomen was achieved with the modified hasson technique. The Nathanson liver retractor was used to lift the left lobe of the liver and expose the gastrojejunal anastomosis. A 30° 10 mm telescope was used for visualization. In both cases, free fluid and purulent material were noted in the subdiaphragmatic region and along the right paracolic gutter. A 1 cm perforation with surrounding inflammatory exudate was identified on the anterior surface in the first case and posterior surface in the second case of the gastrojejunostomy. The edges were debrided and intracorporeal 1-layer repair of the ulcer was performed with simple 2-0 V-lock sutures and covered with an omental onlay patch. The anastomosis was tested with air insufflation and methylene blue dye with no evidence of a leak. A Jackson-Pratt drain was placed in the left upper quadrant.

Results: Both patients underwent an unremarkable hospital course, and follow-up EGD examination after 3 months revealed no evidence of ulceration.

Conclusions: Laparoscopic exploration and the repair of the gastrointestinal perforations in patients with a recent history of MGB is safe, if patients are hemodynamically stable and present within the first 24 hours of the onset of symptoms.

Keywords: Mini gastric bypass (MGB); gastrointestinal perforations; marginal ulcers