Lisandro Montorfano, MD, Fernando Dip, MD, David Nguyen, MD, Joseph Melendez, MD, Emanuele Lo Menzo, MD, PhD, FACS, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS. Cleveland Clinic Florida
Introduction
The incidence of marginal ulcers varies from 0.6% to 16% following a gastrectomy procedure and Billroth II reconstructions. The clinical presentation is unspecific in most cases. For patients who did not respond to medical therapy, surgical management is the indication.
Objective
To determine the feasibility and safety of laparoscopic revision for non-healing gastric ulcers.
Methods
We present a case of a 42 year old female, BMI of 16.13 kg/m2, with abdominal pain, vomiting and weight loss. She had a Bilroth II resection with Braun anastomosis 5 years prior. Using a standard 5 trocar technique the dissection revealed a Billroth II reconstruction with an unusual omega loop type of anastomosis. All limbs were dissected, and the gastrojejunal anastomosis and the loop were resected. A 30 cm biliopancreatic limb remained with approximately an 80 cm alimentary limb. This was then anastomosed to the gastric pouch using a linear stapler and running 2-layer absorbable suture closure, creating a Roux-en-Y configuration. Subsequently, the anastomosis was evaluated for leakage with air and methylene blue.
Results
The patient tolerated the procedure well with minimal blood loss. An upper GI Gastrografin showed no evidence of leak or obstruction. The patient was discharged home on post-operative Day 4 on a pureed diet. Two weeks follow-up was unremarkable.
Conclusion
The presence of recurrent gastrojejunal ulcers is a possible complication of Billroth II resections. Whenever they are not responsive to medical treatment, surgery is indicated. Laparoscopic conversion to Roux en-Y gastrojejunostomy is a viable alternative in treating non-healing gastric ulcers.