Background

Our patient is a 50-year-old woman with a history of open Roux-en-Y gastric bypass 20 years ago who presented with abdominal pain, reflux, and regurgitation over the past year. Previous diagnostic laparoscopy at an outside institution identified Roux and biliopancreatic limbs measuring 50 cm each. Preoperative work-up revealed an enlarged gastric pouch with stasis of contrast on Upper GI, phytobezoar on EGD, and delayed gastric emptying on gastric emptying study. We planned a diagnostic laparoscopy, revision of the gastric pouch, and lengthening of the Roux limb. Intraoperatively, we identified and labeled each limb with different colored sutures. We resected a portion of the gastric pouch and the entire Roux limb. We measured a new 125 cm Roux limb and formed a Roux-en-O loop, with an anastomosis between the proximal and distal ends of the Roux limb. This occurred in part because our labeling suture for the Roux limb was on the original Roux limb and inadvertently removed with the resected specimen. The O reconstruction was deconstructed and converted to a Y reconstruction. We resected the involved bowel and created an isoperistaltic anastomosis at the distal end of the Roux limb to restore continuity. We subsequently formed the common channel approximately 10 cm distal to the previous anastomosis. This case highlights the importance of having a defined system for identification and labeling of each limb in Roux-en-Y gastric bypasses. This is particularly true in revisional cases and in cases in which the original bariatric operation was done at a different institution.