Perforated Stomal Ulcer Following Mini Gastric Bypass Managed by Exploratory Laparotomy and Modified Graham’s Repair: A Case Report

Abstract

Introduction: Perforation of a stomal or marginal ulcer is an uncommon but potentially life-threatening complication after mini gastric bypass (MGB). Chronic NSAID exposure is an important modifiable risk factor. Case Presentation: A 73-year-old man with a history of MGB presented with sudden-onset diffuse abdominal pain and one episode of vomiting. He had a history of chronic NSAID consumption for approximately 25 years and hypothyroidism. Computed tomography demonstrated free intraperitoneal air suggestive of hollow-viscus perforation, with mild ascites, mesenteric and omental oedema, and dilated jejunal loops. Diagnostic laparoscopy revealed purulent contamination, inflamed bowel loops, and a 1 × 1 cm perforation in the stomal/anastomotic region. Because adequate laparoscopic closure could not be achieved, the procedure was converted to exploratory laparotomy. The perforation was repaired using a modified Graham’s omental patch with thorough peritoneal lavage and drain placement. The patient subsequently developed tachypnoea, tachycardia, and hypertension; CT pulmonary angiography excluded pulmonary thromboembolism and demonstrated bilateral pleural effusions with underlying lung collapse. He improved with conservative management and was discharged in stable condition. Conclusion: Perforated stomal ulcer after MGB is a rare surgical emergency. Early recognition, prompt operative management, and an individualised approach to laparoscopic versus open repair are essential. When direct laparoscopic closure is technically difficult, conversion to open surgery and reinforcement with an omental patch may be considered according to intraoperative findings.