Damage control surgery in a perforated marginal ulcer with gastrogastric fistula after Roux-en-Y gastric bypass: a case report

Introduction: Obesity is a prevalent disease with a continuously rising global incidence. Bariatric surgery, particularly Roux-en-Y gastric bypass (RYGB), is an effective long-term treatment for morbid obesity, but it may be associated with late complications, including marginal ulcers and gastrogastric fistulas. Although uncommon, these complications can present with a wide clinical spectrum and may require complex management strategies. Case report: We report the case of a 52-year-old woman with a history of RYGB 4 years earlier who presented to the emergency department in septic shock. Abdominal examination revealed generalized tenderness with guarding. An abdominal X-ray demonstrated pneumoperitoneum. The patient underwent an emergent exploratory laparotomy, which revealed a perforated marginal ulcer associated with a gastrogastric fistula. Damage-control surgery was undertaken with remnant gastrectomy, Roux-limb resection, and temporary abdominal closure. A staged surgical approach was used, with delayed reconstruction via esophagojejunal anastomosis and placement of a feeding jejunostomy. Despite a complicated postoperative course, the patient recovered and was discharged in good clinical condition. Histological examination showed no malignancy. Discussion: Surgical intervention remains the definitive treatment in hemodynamically unstable patients with perforation and uncontrolled intra-abdominal sepsis following bariatric procedures. The authors present a rare case of an acute perforated marginal ulcer associated with a gastrogastric fistula in septic shock, successfully managed using a damage-control approach. Conclusion: Early recognition and prompt individualized management are crucial in severe post–RYGB complications. In critically ill patients, damage control surgery with a staged approach may represent a reasonable strategy to achieve source control and improve outcomes.