Perforated duodenal ulcer after laparoscopic roux-en-Y gastric bypass for morbid obesity

Abstract

© 2018, Faculty of Medicine Siriraj Hospital, Mahidol University. Objective: Duodenal ulcer perforation after laparoscopic Roux-ex-Y gastric bypass (LRYGB) for morbidly obese patient is uncommon. However, the morbidity and mortality rate will be increased if the diagnosis is delayed. We reported clinical presentations, surgical approach as well as outcome of first perforated duodenal ulcer after LRYGB in E-Da hospital. Case presentation: A 34 years old morbidly obese female who underwent successful LRYGB in 2006. Five years later, she developed severe epigastric pain and marked tenderness at this area. No pneumoperitoneum was demonstrated on abdominal CT scan. First diagnostic laparoscopy was done and showed unexplained hemoperitoneum at subhepatic area without definite cause of abdominal pain. Unfortunately, she had to undergo re-diagnostic laparoscopy on postoperative day 2 because bile content was present in abdominal drain. Luckily, the perforated duodenal ulcer was detected at 1st part of duodenum and closed properly by simple suture techniques. Postoperatively, there was no complication and she was discharged home uneventfully. Helicobacter pylori and life-long proton pump inhibitor were prescribed. Upon 3-month follow-up, she had no abdominal pain or other complications. Conclusion: The diagnosis of perforated duodenal ulcer after LRYGB for morbidly obese patients is challenging. Although laparoscopic simple suture is safe and feasible in acute perforated scenario, this might carry high recurrent rate due to the remaining parietal cells in gastric remnant. Nevertheless, the role and timing of definitive acidreducing surgery need to be addressed by having well-designed studies in future.