Late perforation of the jejuno-jejunal anastomosis following Roux-en-Y gastric bypass: A rare clinical observation

Dear Editor,

Roux-en-Y gastric bypass (RYGB) remains one of the most effective surgical treatments for severe obesity, providing durable weight loss and significant improvement in obesity-related comorbidities [1], [2], [3], [4], [5], [6], [7]. Although the procedure is considered safe, surgeons should remain vigilant for uncommon late complications that may present with nonspecific clinical manifestations. Among these, delayed perforation of the jejuno-jejunal (JJ) anastomosis is exceptionally rare, with an incidence reported to be less than 1% [8], [9], [10]. Owing to its rarity and potentially life-threatening consequences, prompt recognition and surgical intervention are essential. We report a case of sealed late JJ anastomotic perforation occurring nine weeks after an otherwise uncomplicated laparoscopic RYGB to emphasize the importance of maintaining a high index of suspicion in patients presenting with abdominal pain during the postoperative period.

A 22-year-old female with morbid obesity (body mass index 47 kg/m²; weight 131 kg) underwent an uncomplicated laparoscopic RYGB. Her initial postoperative recovery was uneventful. Nine weeks after surgery, she presented to the emergency department with a two-day history of progressively worsening abdominal pain. She denied any preceding trauma or other precipitating events. Laboratory investigations demonstrated leukocytosis with a white blood cell count of 17,000/mm³ and 86% neutrophils, accompanied by an elevated C-reactive protein level of 11 mg/L. Physical examination revealed a soft abdomen with diffuse tenderness but without generalized peritonitis.

Contrast-enhanced computed tomography of the abdomen and pelvis demonstrated pneumoperitoneum associated with focal thickening of the bowel at the jejuno-jejunal anastomosis and a localized gas collection adjacent to the anastomotic site, raising concern for bowel perforation (Fig. 1). Given these findings, the patient underwent urgent diagnostic laparoscopy. Intraoperatively, inflammatory adhesions and fibrin deposits were identified surrounding the jejuno-jejunal anastomosis, consistent with a sealed perforation (Fig. 2). Reactive peritoneal fluid was present without evidence of active bile leakage. The gastrojejunal anastomosis was tested with methylene blue and remained intact. Thorough laparoscopic peritoneal lavage was performed, and surgical drains were placed. No bowel resection or reconstruction was required because the perforation appeared completely sealed. The postoperative course was uneventful. Oral intake was resumed on postoperative day one, and the patient was discharged home on postoperative day three. At nine-month follow-up, she remained asymptomatic and had achieved satisfactory postoperative weight loss.

Fig. 1.

CT scan showing gas and inflammation at jejuno-jejunal anastomosis.

Fig. 2.

Intraoperative view showing fibrin deposits and inflammation at the jejuno-jejunal anastomosis.

Late perforation of the jejuno-jejunal anastomosis following RYGB has been reported only rarely in the literature [9], [10], [11], [12], [13], [14]. Most published cases have occurred several weeks to years after surgery, highlighting that this complication is not confined to the immediate postoperative period. Elhardello et al. described perforation occurring nine years after RYGB secondary to an ischemic ulcer involving the blind jejunal pouch [11], [14], whereas Kalaiselvan et al. and Goitein et al. reported delayed perforations occurring within the first postoperative months and discussed several possible pathogenic mechanisms [9], [10]. Similarly, Al Kandari et al. described a late small bowel perforation requiring operative intervention and emphasized the diagnostic challenges associated with delayed presentation [13].

The exact pathophysiology of delayed JJ perforation remains incompletely understood. Proposed mechanisms include chronic ischemia at the anastomotic site, ulcer formation, gradual anastomotic weakening, increased intraluminal pressure, distal bowel obstruction, blind-limb syndrome with bacterial overgrowth, chronic inflammation, bezoar formation, stenosis, kinking, or intussusception [9], [10], [11], [12], [13], [14]. Additional factors such as Helicobacter pylori infection, smoking, chronic nonsteroidal anti-inflammatory drug use, and impaired tissue healing may further predispose susceptible patients to ulceration and subsequent perforation [9], [10]. In our patient, no obvious intraoperative cause was identified, suggesting that occult ischemic injury or progressive anastomotic weakening may have contributed to the development of a microscopic perforation that subsequently sealed before surgical exploration.

Clinical presentation may be subtle despite the presence of perforation. Patients often present with abdominal pain associated with inflammatory markers, while physical examination may reveal only localized tenderness without diffuse peritonitis. Consequently, computed tomography remains the imaging modality of choice, although definitive diagnosis frequently depends on surgical exploration [9], [10], [11], [12], [13]. Management should be individualized according to intraoperative findings. Previously reported strategies have included primary closure, resection with reconstruction of the jejuno-jejunal anastomosis, bowel diversion, fistula control, or extensive abdominal lavage [9], [10], [11], [12], [13]. In the present case, the absence of active leakage allowed successful minimally invasive management through laparoscopic exploration, lavage, and drainage alone, resulting in rapid recovery without recurrence during follow-up.

Although delayed jejuno-jejunal perforation after RYGB is exceedingly uncommon, it represents a potentially life-threatening complication that requires early recognition and decisive management. Persistent or worsening abdominal pain occurring weeks or even years after RYGB should prompt careful evaluation for this entity, even in the absence of generalized peritonitis. Early computed tomography followed by timely surgical exploration when clinically indicated may prevent progression to generalized sepsis and improve patient outcomes. Continued reporting of similar cases may further clarify the underlying mechanisms, identify potential risk factors, and assist in developing evidence-based recommendations for diagnosis and management.

CRediT authorship contribution statement

Houssein Haidar Ahmad: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Maryana ELMassri: Methodology, Data curation. Rana Ibrahim: Writing – review & editing, Validation, Project administration.

Patient consent

Written informed consent was obtained from the patient for publication of this report and accompanying images.

Ethical approval

Ethical approval was waived according to institutional policy because this report describes a single clinical case.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare no conflicts of interest.