Background

This video details the case of a 45-year-old woman with a BMI of 65 who had previously undergone a robotic assisted conversion of sleeve gastrectomy to a roux-en-Y gastric bypass. Her history includes hypothyroidism, warfarin-treated VTE, and depression. She presented with symptoms of PO intolerance, bilious emesis, and abdominal pain. An upper endoscopy performed two weeks prior showed a normal gastric pouch and gastrojejunal anastomosis. A CT scan performed on admission to the emergency department did not reveal any evidence of bowel obstruction, stenosis, or gastrointestinal leak. The patient's workup included an upper GI series which showed severely delayed emptying of the pouch and a hyperdynamic roux limb with significant reflux of contrast back into the pouch. The patient underwent a repeat endoscopy which demonstrated grade C esophagitis, a normal gastric pouch, a small marginal ulcer, and biliary staining within the pouch and proximal roux limb. We thus suspected the presence of a roux-en-O anatomy and elected to perform a diagnostic laparoscopy and revision. Intraoperative findings detailed in the video confirmed our suspicions, and a successful conversion of roux-en-Y was completed. The patient’s post-op course was uneventful initially with minimal oral intake and TPN supplementation, but by post-op day 7, tolerating a bariatric full liquid diet. A lovenox bridge was initiated on post-op day 4, with coumadin started that day. She was discharged on post-op day 10. At the 3 week follow-up, she was doing well tolerating a diet and had achieved 6% total weight loss.