Background

Conversion to a Roux-en-Y esophagojejunostomy (RYEJ) is a recognized treatment option for specific complications following Roux-en-Y gastric bypass (RYGB). Esophagojejunostomy leak is a feared and potentially devastating complication, often initially presenting with fever and tachycardia. We present an unexpected case of postoperative fever and tachycardia following esophagojejunostomy revisional surgery for gastric pouch stenosis.

Methods

A 63-year-old male with history of RYGB and truncal vagotomy four years prior presented to our bariatric surgery practice with chief complaint of progressive dysphagia over two years. His symptoms had progressed to liquid intolerance with severe vomiting and weight loss despite serial endoscopic dilatation. Upper gastrointestinal studies confirmed pouch stenosis and conservative management with Axios stent placement initially showed symptomatic improvement and weight regain. However, after stent removal, the patient experienced rapid recurrence of symptoms. A laparoscopic RYEJ was performed, and the patient was discharged after an uneventful postoperative recovery. On the eleventh postoperative day, the patient presented to the emergency department with fever, tachycardia, and leukocytosis concerning for leak.

Results

Computed tomography showed no evidence of leak but instead suggested acute gangrenous cholecystitis. Considering the timeframe from recent surgery, a nonoperative approach with antibiotics and biliary decompression was favored. The patient underwent successful percutaneous cholecystomy tube placement and interval laparoscopic cholecystectomy at three months. The patient has since progressed well, gaining 14kg since RYEJ revision.

Conclusions

Cholecystitis is an unexpected cause of postoperative fever and tachycardia following EJ. Conservative management involving antibiotics and biliary decompression can be performed with interval cholecystectomy.