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DOI: 10.2174/0250688202002022002, 2020, 1(2), 66-70

New Emirates Medical JournalContent list available at: https://newemiratesmedicaljournal.com

CASE REPORT

Perforated One Anastomosis Gastric Bypass, How we Managed and Review ofLiterature

Hayder Al-Masari1,*, Heba Nofal1, Tarek Mahdy1, Reham Ainawi1 and Marwan Rashed1

1Bariatric Unit, Department of General Surgery, Al-Qassimi Hospital, Sharjah, UAE.

Abstract: Marginal ulcer formation remains a common complication of the one anastomosis gastric bypass procedure, where the ulcer can furtherperforate and present as peritonitis. Although this is uncommon, it is considered one of the life-threatening sequelae associated with this surgery.We report here two different cases of perforated marginal ulcers, presented months after the procedure with an acute abdomen, and discuss thesurgical management using the laparoscopic approach to repair the perforation.

Keywords: Anastomosis, Mini gastric bypass, Morbid obesity, Marginal ulcer, Anastomotic perforation, Laparoscopic.

Article History Received: October 28, 2019 Revised: January 24, 2020 Accepted: February 07, 2020

1. INTRODUCTION

The preponderance of morbid obesity has dramaticallyincreased worldwide over the past few decades, and itcontinues to be among the most important health problems inthe world. With many treatment programs available, bariatricsurgery is considered one of the treatment strategies that resultin long-term success and reduction of associated comorbiditieswith minimal risk of relapse and weight regain [1]. Oneanastomosis gastric bypass that is also known as a Mini-GastricBypass (MGB) is a new bariatric procedure that has shownfavorable results in weight loss and resolution of obesity-related comorbidities and has recently gained the acceptance ofthe international community [2].

The one anastomosis gastric bypass has few long-termcomplications. Provisional surgeries are performed on patientswho develop complications such as severe malnutrition, bilereflux [3], ulcer and weight regain and those count for less than5% of the total number of patients. Compared to the RY gastricbypass, OAGB is relatively simpler, has shorter operating time,less operative complications and the rate of long-term risk ofintestinal obstruction and internal herniation associated with itis lesser [4].

In spite the safety of the OAGB, along with itseffectiveness in weight loss and resolution of type 2 diabetesmellitus and the acceptable nutritional complications it carries[5], it still can be associated with several complications that

* Address correspondence to this author at the Bariatric Unit, Department ofGeneral Surgery, Al-Qassimi Hospital, Sharjah, UAE; Tel: 0566298515;E-mail: Hm.hamadi@moh.gov.ae

necessitate early detection and management. One of theseunfortunate complications is the development of a marginalulcer at the gastrojejunostomy site which can be associatedwith further complications of perforation and peritonitis. Thisabstract presents two cases of post-OAGB ulcer formation withan early and delayed perforation at the anastomosis anddiscusses how they were dealt with successfully with thelaparoscopic approach.

2. CASE PRESENTATION 1

A 33 years old male presented to ER in August 2017,complaining of sudden and sharp epigastric pain, tearing innature, and not relieved with usual analgesia. The patient hadlong term heartburn sensation, for which the patient neglectedhimself. Past surgical history included laparoscopic oneanastomosis gastric bypass in 2015. The patient was not on anymedications or vitamin supplements; he was a heavy smokerand had a history of drug addiction to narcotics. The patientwas examined and found to have diffuse abdominal tendernessand sluggish bowel sounds. CT scan was performed andillustrated pneumoperitoneum, free air in the abdomen. (Figs. 1and 2).

A diagnosis of perforated viscous was made; he wasprepared for laparoscopic exploration and repair of anastomoticperforation with omental patch and resuscitation started withIV fluids and broad-spectrum antibiotics. Under completeaseptic technique, Veress needle CO2 insufflation was carriedout to achieve a pneumoperitoneum at 15 mmHg via a palmerpoint, supraumbilical incision which was used as camera entrypoint (vesiport) as well and further three working ports were

Perforated One Anastomosis Gastric Bypass 67

inserted under vision as follows: 10 mm in the rightmidclavicular line and 5 mm in the left midclavicular atappropriate triangulation distances from one another.Exploration confirmed peritonitis with less than 50 ml of puscollected in the right hypochondrium and pus sample wascollected for culture and sensitivity and lavage was carried out.Mobilization of the anastomosis exposed the perforation (Fig.3) and confirmed by pushing air through the nasogastric tubeand observed bubbling in the water instilled around the leak(Fig. 4).

Fig. (1). Showing free air under the diaphragm in the abdomen.

Fig. (2). Free air in the abdomen under the diaphragm.

The closure was carried out transversely using anabsorbable suture (Fig. 5) and reinforced by an omental patch.Copious irrigation of the peritoneal cavity was carried out withnormal saline. Drains were placed near the anastomotic bedand the patient was shifted to an observation room for routinepostoperative care. The 2nd post-op day, gastrografin swallowtest was conducted Fig. (6) that showed no leak and the patientwas discharged in good general condition on the 3rd

postoperative day on double dose PPI.

2.1. Follow up and Outcome

Eight months later, the patient came back complaining ofepigastric pain and heartburn for which OGD was done andshowed bile in the gastric pouch and a remnant suture at the

anastomotic site that was causing him irritation andanastomotic ulceration (Figs. 7 and 8). The patient was thenreferred to the gastroenterology unit for endoscopic sutureremoval after which he was doing well and he was followed for6 months with no symptoms.

Fig. (3). Illustrates of anastomotic perforation.

Fig. (4). Illustrates of bubbling in the water instilled around the leak bypushing air through the NGT.

Fig. (5). Illustrates of closure of perforation by absorbable suture.

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Fig. (6). Gastrografin sallow done and showed no leak, day 2postoperative.

3. CASE PRESENTATION 2

The 2nd case is a young female diabetic and non-smoker.She presented 11 months after one anastomosis bypass an acuteabdomen. CT was done and showed extravasation of contrast.

Immediate diagnostic laparoscopy was done, finding aposterior perforation of a 1.5 cm size, (Fig. 9).

Fig. (7). Showing erythematous friable anastomotic edge.

Repair with vicryl, 0/3 and an omental patch wasperformed, and a drain was inserted.

Post-operative recovery was smooth and oral contraststudy was conducted on the 2nd day with no leak noted. Thepatient was then discharged on the 3rd day with 1 one yearfollow up done showing no recurrence of symptoms.

Fig. (8). Showing the foreign body (remaining suture) in theanastomosis.

Fig. (9). Posterior perforation 11 months after OAGB.

4. DISCUSSION

OAGB is a procedure that has been performed recently.From the surgical point of view, it involves the creation of loopanastomosis between a long and horizontal lesser curvature-based gastric pouch and jejunum at 150–200 cm distance fromthe Treitz ligament [6]. In spite of the fact that OAGB is aneffective bariatric procedure for weight loss, comorbidityresolution, and has low complication rates in the short andmedium terms, it still can be associated with complications thatneed to be prioritized and detected early for better management[5].

In a recent prospective, multicenter, randomized trial, theYOMEGA trial compared the efficacy and safety of oneanastomosis gastric bypass versus Roux-en-Y gastric bypassfor obesity in which they included 117 cases of RYGB – 150cm roux limb, 50 cm BP limb vs. 117 cases of OAGB – 200 cmBP limb, showing mean % EWL in OAGB 87.9% vs. 85.8% inRoux with serious adverse events, SAEs of 24 in OAGB vs. 42in Roux with a P-value of 0.042.

In the literature, the OAGB has been described for aboutten years. The morbidity of the technique varies between 5.5%[7] and 10.3% [8]. Anastomotic perforation after gastric bypasssurgeries is a rare but an ominous and life-threateningcomplication and has been described previously in the surgical

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literature [9 - 11].

In the review of the literature of 2013, the rate ofanastomotic ulcer formation ranges from 0.6% to 8% [12], andfrom 0.5% [13] to 4% [8] as reported in other articles. Out of1000 patients, there was a 2% ulcer rate with 2 cases ofperforated ulcer and 6 fistulae in 1000 operations in the reviewof Chevallier et al [7]. However, in the literature review byMahawar et al., anastomotic fistulae rate ranged from 0.5% to2.3% [12]. While the study by Carbajo et al. [13], described arate of 0.83% fistulae in 1200 patients.

Ulcer formation and perforation are more likely to occur inpatients with risk factors such as smoking, increased use ofNon-steroidal Anti-inflammatory Drugs (NSAIDs) and the useof non-absorbable suture material [14]. Our two patients hadrisk factors for ulcer formation and perforation; in our 1st case,the patient was a long-term, heavy smoker who continued tosmoke after the operation and the 2nd patient was diabetic.

Studies showed that abdominal pain is the most commonsymptom associated with marginal ulcers [15, 16]. Mucosaledema at the site of the anastomosis can cause nausea andvomiting but these are less frequent symptoms [17]. In thesetting of acute perforation, diagnosis is often suspected basedon patient history and physical examination alone. Patientsusually have a remote history of bariatric surgery and presentwith symptoms of acute abdomen; a detailed history mayreveal previous preceding postprandial pain and nausea orrecent increased use of NSAIDs or smoking. Patients who havefever, tachycardia and signs of peritonitis on physicalexamination do not need additional workup, but usually, aplain abdominal X-ray demonstrating free air in the peritoneumis done to confirm the diagnosis. Patients with less definitivepresentations, like the patients in our cases may require a CTscan to make the definitive diagnosis [18].

There is still no general agreement about the ideal way ofmanaging the perforation of marginal ulcer post-OAGB, due tothe rarity of this complication. For our 2 patients, themanagement depended on laparoscopic exploration first.

We recommend the use of laparoscopic technique to repairthe perforation with omental repair as it has been found to be asafe and feasible option [19] that results in early recovery, lessoperative pain and shorter hospital stay [20, 21], and it is betterfor the intervention to be performed early as the extensiveintraperitoneal spoilage may make the laparoscopic repairdifficult.

To prevent marginal ulcers from being formed, ProtonPump Inhibitors (PPIs) are the treatment of choice, and lifelongtreatment is recommended, this was applied to our twopatients. Yearly regular surveillance with gastro endoscopy isalso strongly recommended to visualize the gastric remnant andmonitor ulcer formation.

CONCLUSION

Marginal ulcer perforation represents one of theproblematic complications after one anastomosis gastric bypassand may present early in the first few months or several yearsafter the surgery. Ulcer causes vary between smoking,ischemia, NSAID and the presence of a foreign body as in our

case. Once diagnosed, marginal ulcer perforation requiresurgent surgical intervention.

ETHICS APPROVAL AND CONSENT TOPARTICIPATE

This study was approved by the Dubai Research EthicsCommittee at Ministry of Health and Prevention, Dubai, UAE.

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Informed consent was obtained by the patients for thepublication of the case details and associated images.

STANDARD FOR REPORTING

CARE guidelines have been followed in this case report.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial orotherwise.

ACKNOWLEDGEMENTS

The authors would like to thank the patients for theirparticipation and consent to the publication of the case detailsand associated images.

REFERENCES

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