Perforation as the First Manifestation of Marginal Ulcer Following One Anastomosis Gastric Bypass: a Multicenter Case Series and Review of Literature

Abstract

One anastomosis gastric bypass (OAGB) has attracted increasing attention over the past decades due to its higher safety, simplicity, and efficacy over other bariatric techniques. Marginal ulcers (MUs) after OAGB are usually asymptomatic, potentially leading to life-threatening conditions, such as bleeding and perforation. However, the precise mechanisms and predisposing factors of perforation at the anastomotic site of OAGB remain unknown. In this study, we report six patients with a history of laparoscopic OAGB presenting with an acute abdomen and pneumoperitoneum. All patients underwent an open surgical intervention after the initial resuscitation. All patients underwent an exploratory laparotomy. Four patients were treated with omental patch repair. For one of them, Braun’s side-to-side jejunojejunostomy was also performed. One patient converted to Roux-en-Y gastric bypass (RYGB), and one patient converted to normal anatomy. Five out of six patients showed favorable outcomes after management. However, one of the patients, which presented with septic shock, expired 24 h after the emergent exploratory laparotomy. The mean interval between OAGB and MU perforation was 19 months, and the mean size of perforation was 2.08 cm. Perforation of an anastomotic ulcer after OAGB is rare and should be included in the differential diagnosis of patients presenting with an acute abdomen following OAGB; this may even occur years after OAGB. Patients can present with a perforated MU as the first manifestation. Adequate fluid resuscitation, along with administration of proton pump inhibitors (PPI) and antibiotics, should be considered in the primary management. Surgical options (oversewing, conversion to RYGB, and conversion to normal anatomy) vary according to the patient’s general condition, size and location of the perforation, and degree of contamination.