Сase of successful treatment of chronic gastric remnant haemorrhagic ulcer after Roux-en-Y gastric bypass

Acute bleeding from a gastric remnant ulcer is an exceptionally rare complication, especially if it occurs several years after bariatric surgery. We present a case of a patient with a bleeding gastric remnant ulcer that occurred 6 years (2013–2019) after the Roux-en-Y Gastric Bypass (RYGB) performed for morbid obesity. The patient was urgently hospitalized in the surgical department with the clinic of gastrointestinal bleeding, according to fibroesophagogastroscopy, no sources of bleeding were found in the examined departments. On the background of conservative treatment, there was an improvement in the condition, but on the fifth day of hospitalization there was a clinic of recurrence of bleeding, while repeated emergency endoscopic examination of the sources also did not reveal. In this regard, it was decided to perform surgery to examine the «residual» stomach. With the help of laparoscopic transgastric gastroduodenoscopy, we were able to detect the source of active bleeding in the stomach excluded from digestion - a bleeding ulcer in the area of small curvature. The removal of this stomach was performed with a good postoperative recovery: the patient was discharged in a satisfactory condition for outpatient treatment, currently feels well, returned to work.

1. Дедов И.И., Мельниченко Г.А., Шестакова М.В., и др. Национальные клинические рекомендации по лечению морбидного ожирения у взрослых. 3-ий пересмотр (лечение морбидного ожирения у взрослых). // Ожирение и метаболизм. — 2018. — Т. 15. — №1. — С. 53-70. [Dedov II, Melnichenko GA, Shestakova MV, et al. Russian national clinical recommendations for morbid obesity treatment in adults. 3rd revision (Morbid obesity treatment in adults). Obesity and metabolism. 2018;15(1):53-70. (In Russ.)] DOI:10.14341/OMET2018153-70

2. Ivanecz A, Sremec M, Ćeranić D, et al. Life threatening bleeding from duodenal ulcer after Roux-en-Y gastric bypass: Case report and review of the literature. World J Gastrointest Endosc. 2014;6(12):625-629. doi:10.4253/wjge.v6.i12.625

3. Яшков Ю.И., Луцевич О.Э., Никольский А.В., Бекузаров Д.К. Сравнительная оценка различных оперативных методов лечения ожирения. // Ожирение и метаболизм. — 2008. — Т. 5. — №1. — С. 31-38. [Yashkov YI, Lutsevich OE, Nikol’skiy AV, Bekuzarov DK. Comparative evaluation of different operative methods for treating obesity. Obesity and metabolism. 2008;5(1):31-38. (In Russ.)] DOI:10.14341/OMET2008131-38

4. Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy. 2011;43(11):950-954. DOI:10.1055/s-0030-1256951

5. Issa H, Al-Saif O, Al-Momen S, et al. Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy. Ann Saudi Med. 2010;30(1):67-69. DOI:10.4103/0256-4947.59382

6. Coblijn UK, Lagarde SM, Tuynman J, et al. Delayed Massive Bleeding Two Years After Roux-en-Y Gastric Bypass. JSLS. 2013;17(3):476-480. DOI:10.4293/108680813x13693422518470

7. Patrascu S, Ponz CB, Ananin SF, Soler EMT. A delayed acute complication of bariatric surgery: Gastric remnant haemorrhagic ulcer after Roux-en-Y gastric bypass. J Minim Access Surg. 2018;14(1):68-70. DOI:10.4103/jmas.jmas_148_16

8. Ceppa FA, Gagné DJ, Papasavas PK, Caushaj PF. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007;3(1):21-24. DOI:10.1016/j.soard.2006.08.018

9. Husain S, Ahmed AR, Johnson J, et al. CT Scan Diagnosis of Bleeding Peptic Ulcer after Gastric Bypass. Obes Surg. 2007;17(11):1520-1522. DOI:10.1007/s11695-008-9433-y

10. Ramaswamy RS, Choi HW, Mouser HC, et al. Role of interventional radiology in the management of acute gastrointestinal bleeding. World J Radiol. 2014;6(4):82-92. DOI:10.4329/wjr.v6.i4.82

11. Kitamura RK, Lee J, Katz LB. The Management of GI bleeding after Gastric Bypass Surgery. Int J Surg Res Pract. 2015;2(2):26. DOI:10.23937/2378-3397/1410026

12. Puri V, Alagappan A, Rubin M, Merola S. Management of bleeding from gastric remnant after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2012;8(1):e3-5. DOI:10.1016/j.soard.2010.08.015

13. Iranmanesh P, Manisundaran NV, Bajwa KS, et al. Management of Acute Gastric Remnant Complications After Roux-en-Y Gastric Bypass: a Single-Center Case Series. Obes Surg. 2020. DOI:10.1007/s11695-020-04537-w

14. Roberts KE, Panait L, Duffy AJ, et al. Laparoscopic-assisted transgastric endoscopy: current indications and future implications. JSLS. 2008;12(1):30-36.

15. Sundbom M, Nyman R, Hedenström H, Gustavsson S. Investigation of the Excluded Stomach after Roux-en-Y Gastric Bypass. Obes Surg. 2001;11(1):25–27. DOI:10.1381/096089201321454060