Background

We Present the case of a 61-year-old male with history of open retrocolic-retrogastric Roux-en-Y gastric bypass who required revisional surgery for refractory duodenal ulcers and stenosis leading to remanent gastric outlet obstruction. Our patient suffered from perforated duodenal ulcers requiring operative washouts and repairs, and imaging guided drainage procedures that ultimately developed duodenal stenosis and an outlet obstruction of the remnant stomach requiring a gastrostomy tube placement. Persistent morbidity from the gastrostomy tube and abdominal pain encouraged us to pursue more definitive management. A laparoscopic assisted trans-gastric remnant gastroduodenoscopy confirmed duodenal stenosis and biopsy proved benign disease. Our plan was to either perform a remnant gastrectomy or an internal bypass procedure to help relieve his symptoms and remove his gastrostomy tube. With significant adhesions and inflammation of the duodenum there were significant challenges and elevated risk for duodenal stump leak, we opted for an internal drainage procedure. We performed a gastrojejunostomy between the remanent stomach and a loop of the biliopancreatic limb to relieve his gastric outlet obstruction and divert acid away from the duodenum. We successfully rid him of his gastrostomy tube and utilized his previous gastrotomy to create the gastrojejunostomy. Postoperatively he did very well and continues to use a proton pump inhibitor to reduce acid production. At early follow-up he has been tolerating a diet and his pain has significantly improved. Long term follow-up is pending.