Late marginal ulcer perforation after Roux-en-Y Gastric bypass - A case report with two-step management

Introduction: Marginal ulcers are an acid-related complication of laparoscopic Roux-en-Y gastric bypass. Few cases of acute perforation have been described, and there are few reports on viable surgical management. This case report demonstrates a two-step surgical procedure for treating a perforated late marginal ulcer in a patient with sepsis. Presentation of case: A 39-year-old smoker presented to the emergency department six years after undergoing a Roux-en-Y gastric bypass. Diagnostic findings revealed ascites and changes in intestinal calibre, indicating the need for surgery. Intraoperatively, a perforated marginal ulcer covered by the liver was observed. Given the extent of the perforation and the patient's increased instability, discontinuity resection was performed. After stabilisation and improvement in the nutritional status, the gastrojejunostomy was restored nine weeks later. Discussion: Treatment of Marginal ulcers is controversial, with no clear guidelines. However, severe complications require endoscopic or surgical treatment. The literature considers three main surgical treatment options for perforated marginal ulcers: surgical repair, surgical anastomotic revision, and gastric bypass reversal. Complicated situations, significant intraoperative findings, and unstable patients require tailored approaches. Conclusion: A two-step procedure with discontinuity resection for damage control surgery, patient stabilisation, and improvement of nutritional status, followed by elective continuity restoration with a new gastrojejunostomy, is considered feasible in critically ill patients.