Background

Patient is a female in her 40s with a complex surgical history, including a sleeve gastrectomy a gastric bypass, a revision of her bypass with distalization procedure at outside hospital, who presented with recurrent issues of bilious emesis, nausea, abdominal pain, and malnutrition. She underwent multiple studies and procedures including EGDs, CTAP, HIDA scan, Ph studies and a sphincterotomy of sphincter of oddi dysfunction. Referral indicated severe bile reflux with a short roux limb as well as multiple anastomosis at the JJ on EGD. A diagnostic laparoscopy revealed intricate anatomy, showing a very short Roux limb and BP limb with diverting loop anastomosis from BP limb to the common channel along with a blind end at the JJ. Multiple areas required resection to address the abnormal anatomy. The biliopancreatic limb, Roux limb and jejunojejunostomy were all reconstructed requiring multiple anastomosis and lengthening of both the roux and Biliopancreatic limb. Mesenteric defects were all closed, and endoscopy confirmed the revised anatomy proximally. She also underwent a hiatal hernia repair with diaphragm closure. The patient, having tolerated the procedure well, was discharged on the fifth postoperative day, with resolved preoperative symptoms. This case underscores the challenges of managing complex post-bariatric complications, necessitating intricate surgical interventions to address the anatomical abnormalities contributing to the patient's symptoms.