Perforated Duodenal Ulcer After Laparoscopic Gastric Bypass

Abstract

A patient with a history of a laparoscopic gastric bypass presented with a perforated duodenal ulcer. The ulcer was laparoscopically oversewn, and an omentoplasty was performed. Postoperatively, a broad spectrum antibiotic and a proton pump inhibitor were administrated. Several questions arise regarding the diagnosis and treatment of duodenal ulcers after gastric bypass. What are the diagnostic tools to detect a duodenal ulcer, and how should Helicobacter pylori be diagnosed after gastric bypass? The key question is whether the bypassed stomach should be resected as a definitive treatment for complicated duodenal ulcers.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

“…Other less common factors may contribute to PPU, such as the use of crack cocaine or amphetamine, and prolonged fasting. The increase in bariatric surgery has resulted in marginal ulcer perforations following Roux‐en‐Y gastric bypass, replacing the stomal ulceration previously seen after gastric resection for malignant disease (such as Billroth II resection). In patients with recurrent or multiple peptic ulcers, the Zollinger–Ellison syndrome (gastrinoma) should not be forgotten.…”

Diagnostic and Therapeutic Double-Balloon Enteroscopy after Small Bowel Roux-en-Y Reconstructive Surgery

“…These types of surgery exclude the stomach, the afferent jejunal limb and the biliopancreatic system from conventional endoscopic investigation. Pathology within the excluded segments may necessitate surgery [21]. However, preliminary data from case reports suggest that interventional double-balloon enteroscopy may prevent redo surgery [7,8,9,10,11,12].…”

Perforated duodenal ulcer after gastric bypass: a challenging diagnosis

“…However, routine removal of the gastric remnant would expose the patients to greater surgical trauma, a prolonged surgical time and, probably, an increased risk for surgical complications and metabolic consequences, such as vitamin B12 deficiency. 5,6 In one series, gastroduodenal perforations presented 20 days to 12 years after the gastric bypass 2 and free air under the diaphragm, the classic radiologic sign of perforation, was not reported in any patients. Most cases were handled by primary closure of the perforation with following definite ulcer therapy in the form of pharmacologic treatment or surgery.…”

“…1 Stool antigen detection is probably the best noninvasive diagnostic tool, with reasonable high sensitivity and specificity, although histological diagnosis remains the gold standard. 5 Therefore, biopsies could be done during surgery for perforated ulcers. In this case, our patient denied doing a digestive endoscopy and H. pylori eradication prior to RYGB and she started eradication therapy after the complication.…”