S4553 Jejunal Ulcers From Abrasion of Retained Suture Material After Roux-en-Y Gastric Bypass: A Rare but Treatable Cause of Abdominal Pain

Introduction: Over 250,000 bariatric procedures were completed in the USA in 2022, with Roux-en-Y gastric bypasses (RYGB) being 1 of the most common operations. These operations manipulate the enteric pathway to exacerbate satiety or decrease absorption and are associated with well-known complications. Early complications include bleeding, wound infection, and coagulopathy. Late complications include marginal ulcers, small bowel obstruction, nutritional deficiencies, and dumping syndrome. Gastroenterologists care for many patients following RYGB. We present a case of a patient with nausea, emesis and abdominal pain after bariatric surgery that improved after cutting excess suture material. Case Description/Methods: A 56-year-old woman with a history of diabetes mellitus type 2 who had RYGB 3 years prior presented to the Gastroenterology clinic with daily episodes of nausea with yellow emesis and intermittent severe abdominal pain. After surgery, she lost 45 lbs and Hg A1C improved from 9.6 to 7.9. She had not responded to proton pump inhibitor (PPI) trial and underwent outpatient esophagogastroduodenoscopy (EGD). Esophagogastroduodenoscopy showed pouch extending 8 cm from Z line and 4.5 cm of excess suture material at the gastrojejunal anastomosis that was extending into the enteral tract. This suture material was causing direct mucosal irritation leading to multiple small jejunal ulcers. Endoscissors were used to cut 3.5 cm of the string that was subsequently removed with jumbo forceps. The patient started daily PPI. She was seen in clinic 6 weeks after the procedure and noted that her abdominal pain had resolved and her symptoms of nausea and emesis were less frequent. She was recommended behavioral modification to ensure small, frequent meals. Discussion: Non-absorbable sutures are an established cause of marginal ulceration in surgical literature. Long sutures can also serve as an incidental nidus for food, blocking it from passing smoothly and resulting in symptoms like abdominal pain, nausea and emesis. Due to this, gastroenterologists should always consider EGD for evaluation of refractory symptoms after RYGB. Moreover, if an anastomosis is healed, suture material can be safely removed endoscopically. In our case, removing suture material significantly improved our patient’s quality of life.