When medical and endoscopic treatment of anastomotic ulcers fails, a surgical resection is the following recommended step. Hostile abdomens with multiple abdominal surgeries are generally approached in open fashion, but with experience these cases can be approached with minimally invasive techniques.
A 48 year-old female presents with melena and abdominal pain in setting of known gastro-jejunal anastomotic ulcer that persisted despite adequate medical treatment. PSH: Roux-en-Y gastric bypass in 2004, redo gastro-jejuno anastomosis and partial left colectomy 2018, left nephrectomy, cholecystectomy and hysterectomy.
A robotic approach was chosen. Initial adhesyolisis using laparoscopic instruments was performed prior to placing the robotic trocars. Extensive adhesyolisis was carried out around the gastro-jejuno anastomosis up to the lower portion of the intrathoracic esophagus. After the remaining stomach with the previous anastomosis were transected (prior tissue perfusion assessment using fluorescence), an esophago-jejuno anastomosis was created using a linear stapler and the resulting ostomy was closed with running sutures of reabsorbable monofilament.
The post-operative course was unremarkable and the patient was discharged on POD3. The last follow up was 1 month post-surgery, where the patient tolerated a soft diet and did not require pain medication. The patient will continue to be followed at regular time intervals with a multidisciplinary team.