A delayed acute complication of bariatric surgery: Gastric remnant haemorrhagic ulcer after Roux-en-Y gastric bypass.

Acute gastric remnant bleeding is an exceptionally rare complication when it occurs long after bariatric surgery. We present the case of a patient with a bleeding ulcer of the excluded stomach (i.e., the remnant), occurring 7 years after Roux-en-Y gastric bypass (RYGB) for morbid obesity. A computed tomography scan managed to locate the active bleeding source in the gastric remnant. During emergency laparotomy, a bleeding ulcer of the fundic region of the excluded stomach was identified. Total resection of the remnant was performed, with good post-operative recovery. To the best of our knowledge, this is the first full report of a significantly delayed haemorrhagic ulcer of the gastric remnant, occurring years after RYGB.

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is considered the gold standard for bariatric surgery, offering an efficient and long-lasting method for weight loss, as well as a significant improvement of type II diabetes, dyslipidaemia and hypertension in obese patients.[1] One major drawback of RYGB is the difficult access to the excluded stomach, which makes the assessment of the morphologic changes in the remnant a challenging process. Delayed acute complications of the biliopancreatic limb and of the excluded stomach after RYGB such as perforation and bleeding have been reported, although most of them are rare incidental findings discovered during emergency surgery.[23]

We report a case of a potentially fatal upper gastrointestinal (GI) bleeding from gastric remnant ulcer, occurring 7 years after RYGB.

CASE REPORT

This is the case of a 52-year-old woman who presented in the emergency setting after several episodes of upper GI bleeding, manifested by melena and mild epigastric pain. She denied tobacco and anti-inflammatory drug use, and perioperative Helicobacter pylori tests were negative. In 2009, the patient underwent a laparoscopic RYGB (pre-operative body mass index [BMI]: 45 kg/m2), followed by two reinterventions for an internal hernia in May 2009 and June 2014, with no enterectomy having been necessary. After the second operation, the patient developed a large ventral hernia. Weight losses of 41 kg at 6 months and 74 kg at 18 months after surgery were recorded. At the most recent admission, the patient had a BMI of 21.9 kg/m2 and percentage of excess weight loss of 97%.

Two weeks before the current haemorrhagic episode, the patient reported intermittent emission of melenic stools and self-limited epigastric pain, for which she was admitted to a local hospital. The patient underwent an emergency endoscopy, which showed no pathological findings. However, a computed tomography (CT) scan demonstrated dense fluid material in the common intestinal limb, near the anastomosis. The patient was transferred to our surgical department for further investigation. A second endoscopy was performed during the next 24 h, revealing no signs of bleeding in the gastric pouch, Roux limb, or the entero-entero-anastomosis, but we were unable to visualise the bypassed segment. H. pylori testing was again negative. On admission, laboratory findings were unremarkable except for a haemoglobin level of 8.9 g/dL.

After a rather favourable clinical evolution, during the 6th day of the admission, the general status of the patient began to alter, as she developed unexpected tachycardia and hypotension. However, no abdominal pain or melenic stools were recorded during the previous 24 h. As the laboratory findings showed a haemoglobin level of 6.9 g/dL, the patient received a 2-unit red blood cell transfusion. A double contrast CT scan was performed, revealing possible bleeding in the fundic region [Figure 1].

Figure 1

Double contrast computed tomography image of the gastric remnant haemorrhagic ulcer (red arrow)

The decision was made to perform an emergency exploratory laparotomy, which showed multiple adhesions of the gastric remnant attached to the diaphragm and spleen. A small anterior gastrotomy was performed, which revealed approximately 200 mL of fresh blood in the excluded stomach. Therefore, the gastrotomy was extended to determine the source of bleeding. A 1.5-cm actively bleeding ulcer was identified in the fundic region, which was adherent to the spleen. After careful dissection, the remnant was released from its adhesions, thus allowing for its resection. Primary closure of the abdominal wall could not be performed due to the large ventral hernia, so a prosthetic mesh was considered necessary as a fascial substitute. The histopathological examination of the surgical specimen confirmed the benign nature of the ulcer [Figure 2]. The post-operative course was uneventful, with hospital discharge on the 13th post-operative day. At 2-month follow-up, the patient had no further episodes of upper GI bleeding.

Figure 2

Glandular pattern with a marked inflammatory component, consisting of abundant leukocytes (a) and an inflammatory foreign body reaction (b) (H and E staining, ×10)

DISCUSSION

Delayed upper GI bleeding after RYGB occurs mainly as a complication of marginal ulcerations, with an incidence between 0.6% and 16%.[45] Fortunately, marginal ulcers can be diagnosed and treated via endoscopy in most cases. In contrast, bleeding from the biliopancreatic limb is an extremely rare event, mainly involving bleeding duodenal ulcers.[23678]

A major issue for the distal remnant is difficult endoscopic access. The standard esophagogastroscopy is important in excluding any source of bleeding down to the gastrojejunal anastomosis, and even further to the jejunojejunostomy; however, it is limited by its inability to reach the biliopancreatic limb. The creation of a percutaneous distal gastrostomy (either by ultrasonography or CT guidance) or a laparoscopic gastroduodenoscopy can sometimes provide adequate visualisation and treat bleeding from the remnant. In addition, enteroscopy is another less invasive alternative.[2] Despite their diagnostic and therapeutic use, all these methods are cumbersome; therefore, they are rarely used in the current practice. Whenever the source of bleeding obscures the use of more conventional diagnostic methods, intraoperative endoscopy of the excluded stomach during exploratory laparotomy can be used.[29] This approach offers major advantages, as it allows not only proper visualisation of the remnant, duodenum and the blind intestinal limb but also provides a potentially curative solution.

In the case of gastric remnant bleeding, besides endoscopy, there are several other diagnostic tools that have been advocated, such as CT angiography, technetium-99m red blood cell scanning and celiac angiography. A major drawback of some of these techniques is the inconclusive results when dealing with intermittent bleeding.[2] However, arterial embolisation for upper GI bleeding using different embolic agents (e.g., microcoils, polyvinyl alcohol particles, gelfoam and N-butyl-2-cyanoacrylate glue) has found its use as an excellent alternative for unsuccessful endoscopic haemostasis. The altered anatomy after RYGB, which does not allow for conventional endoscopic exploration, could provide the perfect indication for this type of endovascular approach.[1011]

The ultimate treatment for gastric remnant bleeding remains surgery. Although laparoscopy has undeniable advantages over open access, its use frequently contraindicates the haemodynamic status of the patient. Furthermore, post-operative adhesions, as in our case, could make the surgical intervention even more complex and time-consuming.

One special point of interest is the type of procedure that should be used. For any acute complications of the remnant, diagnosis can be challenging due to the altered symptomatology, difficult endoscopic access, and inconclusive radiographic images. As a result, surgery is often delayed, with potential life-threatening consequences. Therefore, it may be more beneficial for surgeons managing this condition to consider a definitive treatment such as gastric remnant resection, thus eliminating the risk of any further complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.