IBC Oxford Oral Abstract 38 - Marginal ulcer, alkaline reflux gastritis, and dumping syndrome: conversion to Duodeno-ileal interposition due to inadequate revision after gastric bypass

Abstract Objective This case report and video presentation aim to present the surgical treatment method applied to a patient who had previously undergone multiple bariatric surgeries, including two significant revisions, and developed complications, including marginal ulcer (MU), dumping syndrome, and duodenogastric alkaline reflux. Video case The patient (59-year-old female) with obesity and type 2 diabetes (110 kg/163 cm, BMI: 41.4 kg/m2) underwent laparoscopic sleeve gastrectomy in 2014. After six years, a conversion to Roux-en-y Gastric Bypass (RYGB) in 2020 was performed due to weight regain and Gastroesophageal Reflux Disease (GERD) (87 kg/163 cm, BMI: 32.8 kg/m2). After RYGB, the patient failed to lose weight and developed stomach pain three to four months later. Endoscopy revealed three deep marginal ulcers (MU) at the gastrojejunostomy (GJ) line. Despite a rigorous medical treatment and follow-up of 3 years, her marginal ulcers did not resolve, and she went through another revision surgery (jejunal-gastrostomy) that left the ulcerated gastrojejunostomy untouched while connecting the remnant stomach to the proximal pouch by a jejunal bridge in between. She started vomiting bile and had a stricture after this procedure, needing four endoscopic dilatations at two monthly intervals. She presented to our clinic with severe abdominal pain radiating to the back, class II obesity (96 kg/163 cm, BMI: 36 kg/m2), and vomiting of bile. The evaluation showed persistent marginal ulcers and biliary duodenogastric reflux. To minimize the risk of severe malabsorptive complications due to the patient’s class II obesity, the duodenal switch was not chosen for revision. Instead, Duodenoileal Interposition, which has a lower malabsorptive component, was planned. In May 2024, the patient underwent resection of the jejunal segment with ulcerated anastomosis along with a gastro-gastrostomy (GGA) between the remnant stomach and upper gastric pouch. The remaining part of the planned revision was postponed, allowing the GGA to heal. Two months later, in July 2024, the Duodeno-ileal Interposition was performed to divert bile reflux and achieve weight control. Postoperatively, the patient’s stomach pain improved, and symptoms of biliary duodenogastric reflux were resolved. Weight control was initiated, and the patient lost 12 kg. Endoscopy showed no signs of MU or bile reflux. Conclusion This case demonstrates the effectiveness of removing the ulcerated anastomosis in treating persistent MU after RYGB. In cases where MU persists despite medical treatment, which is the first line of therapy, surgical resection of the ulcerated area and creating a stomach-to-stomach connection may reduce the risk of recurrent MU. Duodeno-ileal Interposition can be safely applied to correct alkaline reflux, especially in patients with obesity and type 2 diabetes.