Introduction: Esophagectomy in patients with a history of Roux-en-Y gastric bypass is rare in medical literature and a challenging situation.

Methods: We present a case of an 81-year-old male patient, who had Roux-en-Y gastric bypass in the past, now with a distal esophagus adenocarcinoma. A minimally invasive Ivor Lewis esophagectomy with gastric remnant pull-up was planned.

Results: After laparoscopic access, the mobilization and transection of the alimentary limb and the gastric pouch were performed. The lesion was resected and histopathologic analysis showed free margins. An intraoperative esophagogastroduodenoscopy was attempted to verify if a Merendino procedure would be possible instead of an Ivor-Lewis esophagectomy. However, the lesion appeared to be higher than expected and the former would not be feasible. The patient desaturated and the surgery was converted to open laparotomy. After stabilization, a feeding jejunostomy was placed distal to the prior jejunojejunostomy. Then, a gastric tube was performed with a linear stapler and placed into the thorax. After thoracoscopy, the graft and esophagus were verified for perfusion with Indocyanine green fluorescence showing good blood supply. An end-to-side esophagogastrostomy was then performed with a circular stapler. The patient tolerated the procedure well and was transferred to ICU in stable condition. He was discharged on 14^th postoperative day.

Conclusion: Roux-en-Y gastric bypass is a common procedure for treating morbid obesity. Therefore, surgeons must know the complexity of the altered GI tract for possible reoperative interventions, such as esophageal cancer resection.