Background

We present the technical details of complex laparoscopic revision for a giant 'kissing' almost circumferential chronic gastrojejunal marginal ulcer eroded into anterior abdominal wall and into the Sleeve Remnant after a remote laparoscopic conversion of a Sleeve Gastrectomy (LSG) to a Roux-en-Y Gastric Bypass (RYGB). The patient is a 76-year-old female, with BMI of 29 kg/m2, who was referred to our practice with a two year history of abdominal pain and narcotic dependency. The index LSG was done in 2012 for a BMI of 40, which was converted laparoscopically to RYGB for severe denovo GERD in 2015. She had an additional emergency surgery in 2017 that was described laparoscopic Graham patch for a 'perforated ulcer' in the remnant of the LSG. After 2017 she had multiple upper endoscopies showing a marginal ulcer and was dependent on narcotics for pain control. At endoscopy in our center we found large 'kissing' almost circumferential chronic gastrojejunal marginal ulcer eroded for about 2 cm into the anterior abdominal wall and posterior 1 cm ulcer eroded into the Sleeve Remnant with a 0.9 cm long jenunal stricture. The video shows the technical details of the challenging laparoscopic lysis of adhesions to detach the ulcer eroded into the abdominal wall, mobilization and en-block resection of the GJ ulcer-remnant stomach complex, trimming of the long gastric pouch and the new gastrojejunal anastomosis using a circular stapler. The patient had an uneventful recovery, was weaned off narcotics in two weeks and remain narcotic and pain free at follow-up.