Late Gastric Remnant Necrosis Associated with Paraesophageal Hernia After Roux-en-Y Gastric Bypass

Gastric remnant ischemia is a rare but life-threatening complication after Roux-en-Y gastric bypass. We report a 65-year-old man who presented nearly 20 years after bypass with acute left upper quadrant pain, nausea, and vomiting. Computed tomography (CT) demonstrated marked distention of the excluded gastric remnant with pneumatosis, without evidence of small bowel obstruction, biliopancreatic limb obstruction, or mesenteric vascular occlusion. Diagnostic laparoscopy revealed a severely distended and ischemic gastric remnant, and indocyanine green angiography confirmed absent perfusion. The patient underwent laparoscopic resection of the ischemic remnant and repair of an associated paraesophageal hernia containing the gastric pouch. He recovered without complications. Recent tirzepatide use may have contributed to impaired remnant emptying and progressive distention, although causality cannot be established. This case highlights the importance of considering remnant pathology in postbypass patients with acute abdominal pain and demonstrates the utility of minimally invasive exploration with fluorescence-guided perfusion assessment.