Unexpected Biliopancreatic Limb Obstruction after Gastric Bypass Revision.

INTRODUCTION: Biliopancreatic limb obstruction is a surgical emergency in patients who have undergone gastric bypass surgery. This case report presents an unexpected cause of biliopancreatic limb obstruction and the importance of prompt intervention.

MATERIAL AND METHODS: A 37-year-old woman presented with complaints of weight regain (BMI increased from 27 to 33.3 kg/m2 ) and bile reflux and was found to have marginal ulcers on endoscopy. She had undergone loop gastric bypass with Braun anastomosis in 2009 at another center for morbid obesity (BMI = 43 kg/m2 ). Roux-en-Y gastric bypass (RYGB) was created after the separation of gastro-jejunostomy (GJ) and jejuno-jejunostomy (JJ). On the fifth postoperative day, the patient was readmitted with signs of peritonitis. Urgent relaparoscopy showed Biliopancreatic limb (BP) obstruction. It was then and that we understood intraoperatively the uncut Roux-en-Y caused stricture between the previous GJ and JJ staple lines. Side-to-side jejuno-jejunostomy between the proximal dilated and the distal collapsed biliopancreatic limb was performed.

RESULT: The patient recovered uneventfully and was discharged after drain removal.

CONCLUSION: Biliopancreatic limb obstruction requires prompt decision for relaparoscopy. Timely intervention is necessary to prevent postoperative morbidity. Reviewing the operative video or notes of the primary surgery can minimize the chance of mismanagement during revision surgery.