Alimentary Limb Ischemia During Roux-en-Y Gastric Bypass and its Management.
INTRODUCTION
Ischemia of the tip of the alimentary limb involving the gastrojejunostomy (GJ) is an unusual complication during Roux-en-Y gastric bypass (RYGB). Revision of the GJ may be needed to manage this complication.


OBJECTIVES
We present a case of inadvertent perforation of the jejunum by a gastric calibration tube, which was recognized on the table and appropriate measures are then taken. Repair of this enterotomy however then led to ischemia of the tip of alimentary limb extending to a portion of the GJ anastomosis. We present its subsequent management.


METHODS
Our patient is a morbidly obese female patient with a BMI value of 44.6 kg/msq undergoing RYGB. We performed an antecolic, antegastric linear-stapled gastrojejunostomy of 2.5 cm. After hand-sewn closure of the common enterotomy, we tried passing a 38-F Bougie through the anastomosis into the Roux limb. During this maneuver, the Bougie inadvertently perforated the Roux limb at the mesenteric border. Following the repair of this jejunal rent, the distal part of the Roux limb became dusky and involved a portion of the gastrojejunal anastomosis. The gastrojejunostomy was therefore completely revised. Intraoperatively, methylene blue dye test was done which showed no leak.


RESULTS
Post-operative gastrografin study revealed no leak and liquids were started on POD1.


CONCLUSION
Inadvertent injury by a Bougie is a rare but known complication in laparoscopic RYGB. Intraoperative recognition of the complication is essential to prompt the necessary repair. Revision of the gastrojejunostomy is necessary if the Roux limb or the anastomosis itself is ischemic and can be accomplished with good results.
['Mittal|Tarun|T|0000-0003-0780-2201', 'Dey|Ashish|A|', 'Nali|Abhilash|A|', 'Taha Mustafa|Sheikh Mohammad|SM|', 'Malik|Vinod K|VK|']
D005260:Female D015390:Gastric Bypass D006801:Humans D007511:Ischemia D007583:Jejunum D010535:Laparoscopy D009767:Obesity, Morbid D012086:Reoperation
Alimentary limb ischemia Roux-en-Y gastric bypass Management RYGB Bougie