Marginal ulcer causing delayed anastomotic perforation following one anastomosis gastric bypass (OAGB)

Background: One anastomosis gastric bypass (OAGB) is gaining favor. Anastomotic perforation is a dreaded complication. Objectives: To describe a series of patients presenting with delayed (> 90 days) perforation of a marginal ulcer (MU) following OAGB. Setting: Two university hospitals, Israel. Methods: A retrospective query identifying patients after OAGB admitted with delayed MU perforation. Demographic characteristics, time between OAGB to presentation, clinical, laboratory and imaging at presentation and management data were collected. Results: Between 1/2017–1/2020, 7 patients were identified. Mean body mass index (BMI) and time difference between OAGB and perforation were 14 kg/m² (range 7–23) and 13 months (range 4–23), respectively. All presented with upper abdominal pain, 4 had concomitant nausea and vomiting. One patient displayed tachycardia, none had fever and 3 exhibited leukocyte abnormalities. C-reactive protein ranged widely (2–311 mg/L). Mean albumin level was 2.9 g/dL (range 1.9–4). Pneumoperitoneum was demonstrated in half of plain abdominal films and all computed tomography (CT) scans. Management was tailored to clinical status. Four patients underwent laparoscopic primary repair with omentopexy. Two patients were initially managed nonoperatively, one eventually requiring conversion to Roux-en-Y gastric bypass (RYGB) while the other recovered without further intervention. One patient underwent exploratory laparotomy and “damage control” management with pouch gastrostomy and double-barrel jejunostomy. Risk factors for MU were present in 4 cases. Mean length of hospital stay was 18 days (range 3–79 days). Conclusions: Perforation of MU may occur months to years after OAGB even without risk factors. Laboratory results are unreliable. The CT scan is diagnostic. A tailored approach can achieve good outcomes.