Management of rare complications in obese patients after laparoscopic gastric bypass




rare complication, gastric bypass, hemobezoar, marginal ulcer, gastrogastric fistula, Petersen’s space hernia, bleeding


The complications resulting from laparoscopic gastric bypass can be categorised into two main groups: early (within 30 days after surgery) and late (after 30 days following surgery). Bleeding, marginal ulcers, and failure of the suture line occur most often. Stenosis of the anastomotic areas, adhesive small bowel obstruction, incarceration of Petersen’s space hernia, gastrogastric fistula, and hemobezoar‑induced small bowel obstruction are less often observed.

Objective —  to improve the management of rare complications in obese patients after laparoscopic gastric bypass.

Materials and methods. The study includes a retrospective analysis of patients who underwent laparoscopic gastric bypass in the Department of General Surgery No. 2 at Bogomolets National Medical University from 2011 to 2023. Patients aged 25 to 59 who met the IFSO criteria for obesity participated in the research. The minimum observation period was 12 months. All patients underwent a laparoscopic Roux‑en‑Y Gastric Bypass.

Results. The study included a cohort of 348 patients who underwent laparoscopic gastric bypass. The majority of them were female, including 189 individuals (54.3%). A total of 6 patients (1.72%) were identified with rare problems, consisting of 2 women and 4 men. Two patients were diagnosed with acute small bowel obstruction caused by a hemobezoar, one patient with gastrogastric fistula, one patient with acute adhesive small bowel obstruction, one patient with a marginal ulcer of the «large» stomach complicated by perforation, and one patient with a pinched Petersen’s space hernia. All complications were class IIIb, according to the Clavien‑Dindo classification, and required surgical treatment. In the early period, 3 (50%) cases were diagnosed: acute adhesive small bowel obstruction (2 days postoperatively ) and acute small bowel obstruction caused by a hemobezoar (2—3 days postoperatively).

Conclusions. We found that the incidence of rare complications among obese individuals after laparoscopic gastric bypass was 1.72%. Specifically, 1.14% of patients experienced small bowel obstruction, 0.29% had a marginal ulcer of the «large» stomach complicated by perforation, and 0.29% had a pinched Petersen’s space hernia. Each case of a rare complication requires an individual approach to its management.


Author Biography

V. O. Nevmerzhytskyi, Bogomolets National Medical University, Kyiv

Assist. Prof., Department of General Surgery No2


Al Harakeh AB, Kallies KJ, Borgert AJ, Kothari SN. Bowel obstruction rates in antecolic/antegastric versus retrocolic/retrogastric Roux limb gastric bypass: a meta-analysis. Surg Obes Relat Dis. 2016 Jan;12(1):194-8. Epub 2015 Feb 11. PMID: 26003892.

Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy. 2011 Nov;43(11):950-4. Epub 2011 Oct 13. PMID: 21997722.

Baba A, Yamazoe S, Dogru M, Okuyama Y, Mogami T, Kobashi Y, Nozawa Y, Aoyagi Y, Fujisaki H, Ogura M, Matsui J. Petersen hernia after open gastrectomy with Roux-en-Y reconstruction: a report of two cases and literature review. Springerplus. 2015 Dec 2;4:753. PMID: 26693111; PMCID: PMC4666877.

Bacoeur-Ouzillou O, Perinel J, Pelascini E, Abdallah M, Poncet G, Pasquer A, Robert M. Management strategies of anastomotic ulcer after gastric bypass and risk factors of recurrence. Surg Endosc. 2022 Dec;36(12):9129-9135. Epub 2022 Jun 28. PMID: 35764841.

Caputo V, Facchiano E, Soricelli E, Leuratti L, Quartararo G, Lucchese M. Small Bowel Obstruction After Laparoscopic Roux-en-Y Gastric Bypass Caused by Hemobezoar: A Case Series and Review of Literature. Surg Laparosc Endosc Percutan Tech. 2021 Jun 7;31(5):618-623. PMID: 34091483.

Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Villares A, Zundel N, Rosenthal R. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):467-74. Epub 2005 Aug 31. PMID: 16925272.

Chahine E, Kassir R, Dirani M, Joumaa S, Debs T, Chouillard E. Surgical Management of Gastrogastric Fistula After Roux-en-Y Gastric Bypass: 10-Year Experience. Obes Surg. 2018 Apr;28(4):939-944. PMID: 28983751.

Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Wagensveld BA. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg. 2014 Feb;24(2):299-309. PMID: 24234733.

Coblijn UK, Lagarde SM, de Castro SM, Kuiken SD, van Tets WF, van Wagensveld BA. The influence of prophylactic proton pump inhibitor treatment on the development of symptomatic marginal ulceration in Roux-en-Y gastric bypass patients: a historic cohort study. Surg Obes Relat Dis. 2016 Feb;12(2):246-52. Epub 2015 May 7. PMID: 26381875.

Coblijn UK, Lagarde SM, de Castro SM, Kuiken SD, van Wagensveld BA. Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management. Obes Surg. 2015 May;25(5):805-11. PMID: 25381115.

El Nogoomi I, Nouh AK, Jaber AA, Toubah AM, Alkaram SS. Petersen’s Hernia After Roux-en-Y Gastric Bypass: A Case Report. Cureus. 2023 Dec 18;15(12):e50757. PMID: 38239520; PMCID: PMC10796129.

Ende V, Devas N, Zhang X, Yang J, Pryor AD. Internal hernia trends following gastric bypass surgery. Surg Endosc. 2023 Sep;37(9):7183-7191. Epub 2023 Jun 22. PMID: 37349593.

Green J, Ikuine T, Hacker S, Urrego H, Tuggle K. Acute small bowel obstruction due to a large intraluminal blood clot after laparoscopic Roux-en-Y gastric bypass. J Surg Case Rep. 2016 Aug 23;2016(8):rjw143. PMID: 27554828; PMCID: PMC4994514.

Hess DT, Beesley H, Carter CO, Carmine BJ, Pernar LIM. Surgical management of obstructing clot at the jejunojejunostomy after gastric bypass: a single center experience and literature review. Surg Obes Relat Dis. 2021 Apr;17(4):765-770. Epub 2020 Nov 27. PMID: 33414097.

Iannelli A, Facchiano E, Gugenheim J. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg. 2006 Oct;16(10):1265-71. PMID: 17059733.

Iranmanesh P, Manisundaran NV, Bajwa KS, Thosani NC, Felinski MM, Wilson EB, Shah SK. Management of Acute Gastric Remnant Complications After Roux-en-Y Gastric Bypass: a Single-Center Case Series. Obes Surg. 2020 Jul;30(7):2637-2641. PMID: 32162207.

Kojima K, Inokuchi M, Kato K, Motoyama K, Sugihara K. Petersen’s hernia after laparoscopic distal gastrectomy with Roux-en-Y reconstruction for gastric cancer. Gastric Cancer. 2014 Jan;17(1):146-51. Epub 2013 Apr 5. PMID: 23558458.

Muir D, Choi B, Clements C, Ratnasingham K, Irukulla S, Humadi S. Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis. Obes Surg. 2023 Jul;33(7):2229-2236. Epub 2023 May 10. PMID: 37162714.

Nguyen J, Siksik JM, Genser L. Gastro-gastric fistula after gastric bypass. J Visc Surg. 2018 Oct;155(5):431-432. Epub 2018 Aug 6. PMID: 30093308.

Nuytens F, D’Hondt M, Van Rooy F, Vansteenkiste F, Pottel H, Abasbassi M, Servaege A, Devriendt D. Closure of mesenteric defects is associated with a higher incidence of small bowel obstruction due to adhesions after laparoscopic antecolic Roux-en-y gastric bypass: A retrospective cohort study. Int J Surg. 2019 Nov;71:149-155. Epub 2019 Sep 19. PMID: 31542389.

Plitzko G, Schmutz G, Kröll D, Nett PC, Borbély Y. Ulcer Disease in the Excluded Segments after Roux-en-Y Gastric Bypass: a Current Review of the Literature. Obes Surg. 2021 Mar;31(3):1280-1289. Epub 2020 Nov 24. PMID: 33230760; PMCID: PMC7921036.

The 8th IFSO 2022 Registry Report. [Internet]. [cited 2023 Dec 27]. Available from:

Wu QL, Liu QZ, Xi YY, Deng XQ, Xu TS, Xie ZC, Chen JA, Yuan Y. Closed or Unclosed Mesentery? A Meta-analysis of Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2023 Jun;33(6):1900-1909. Epub 2023 Apr 21. PMID: 37081253.






Original Research