Background

Perforated marginal ulcer is a rare but potentially devastating complication following Roux-en-Y gastric bypass (RYGB). Options for surgical treatment of perforated marginal ulcer include repair, with or without omental pedical flap, and revision of the gastrojejunal (GJ) anastomosis. Characteristics of the anastomosis such as the presence of stricture, the extent of perforation, and the temporal duration of marginal ulceration are factors that must be considered to guide operative management. Tissue integrity in the setting of acute perforation as well sequelae of associated chronic inflammation can often make GJ revision a challenging and high risk procedure. Further patient factors such as medical instability, malnourishment, and active tobacco use may compound this difficulty and necessitate alternative operative approaches to address anastomotic complications. We present a case of a 44-year-old female with a remote history of laparoscopic RYGB who presented with a perforated marginal ulcer and severe GJ anastomotic stricture. To avoid complete revision of the gastrojejunostomy in the acute setting, we performed a stricturoplasty incorporating the perforation followed by pedicled omental flap coverage. This is presented as a technically feasible alternative to GJ anastomotic revision that can be utilized for the acute management of a perforated marginal ulcer with significant gastrojejunal stricture.