**Background:** Roux-en-Y gastric bypass (RYGB) reversal is a reoperative procedure performed to resolve complications such as marginal ulcers, anastomotic strictures, gastrogastric fistula, nutritional deficiencies, and weight gain. Despite increasing numbers of RYGB reversals, there are no standardized guidelines for patient selection, and limited data exist on late complications (>30 days postoperatively). Most studies focus on early complications (leak, sepsis, bleeding) with a reported early complication rate of 29% in the largest single-institute study. Long-term follow-up ranges from none to 41 months, and few studies report late outcomes.
**Methods:** This is a single case report of a 51-year-old female who presented to the emergency department with abdominal pain, chronic uncontrolled diarrhea, and inability to tolerate food for six months. She had become TPN-dependent and was taking pantoprazole. Her surgical history included RYGB in 2003 (BMI 48.9 kg/m²), partial colectomy with ostomy for colon cancer with multiple re-do procedures, RYGB reversal to normal anatomy in 2019 (BMI 18.5 kg/m²), ileostomy reversal, and ileorectal anastomotic stricture status post-dilation and stent placement. Initial workup (BMI 29.0 kg/m²) included CT abdomen with contrast showing extensive postsurgical changes, diffuse small bowel dilation, and narrowing at the ileorectal anastomosis. EGD revealed a large anastomotic ulceration at the remnant jejunum of the gastric pouch and a patent but difficult-to-access reversal into the remnant stomach. Sigmoidoscopy showed no distal obstruction. Repeat endoscopy by surgery confirmed ulcers at the remnant jejunum, and the gastrogastrostomy was not patent with only a small cuff of small bowel anastomosed to the pouch. Upper gastrointestinal series showed the gastric pouch needed to be filled completely before overflowing into the remnant stomach, with the gastrogastrostomy placed high along the cardia and nonfunctional. The patient underwent open surgical exploration due to severe adhesive disease. A large gastrotomy was performed on the posterior aspect of the remnant stomach. An endoscope identified a small pinhole connection between the pouch and remnant stomach at the superomedial portion of the fundus at approximately 11 o'clock direction. A silk suture was tied around the endoscope and pulled through. The anvil of a 60-mm GIA black load stapler was passed through the stricture, and two fires of the stapler were used to cross the stricture. The gastrotomy was closed with multiple fires of 60-mm GIA purple loads. Leak test was negative. Blood loss was approximately 100 cc, operative time was four hours.
**Key Results:** The patient's hospital course was complicated by persistent abdominal pain, episodes of emesis and nausea, attributed to residual ulcers at the remnant jejunum or ileus. She was discharged on postoperative day 15 (June 4, 2022) with TPN. She returned with abdominal pain and wound dehiscence, which resolved after wound drainage and incision. At follow-up on June 27, 2022, TPN was discontinued. The patient was gaining weight and eating well. The authors note that the patient's pre-reversal symptoms (recurrent anastomotic ulceration) did not improve after the initial reversal, and she developed a stenosed gastrogastric anastomosis with malnutrition requiring TPN. The pathophysiological mechanism proposed is that the stenotic reversal prevented drainage of the gastric pouch, causing severe gastroesophageal reflux and stasis leading to marginal ulceration.
**Clinical Implications:** This case demonstrates that late complications following RYGB reversal, specifically stenosis of the gastrogastric anastomosis, can occur years after the procedure (2.5 years in this case). The authors note that few, if any, prior cases cite stenosis of the gastrogastric anastomosis as a postoperative complication requiring surgery. The case underscores the need for longer follow-up after RYGB reversal to identify late complications and better prepare physicians for managing such patients. The authors also highlight the technical challenges of reoperative surgery in patients with multiple prior abdominal procedures, including severe adhesive disease and altered anatomy, which may necessitate conversion from laparoscopic to open approach.