© FD-Communications Inc. Obesity Surgery, 13, 2003 797 Obesity Surgery, 13, 797-799 Access to the bypassed stomach is difficult following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The bypassed stomach is not readily available for endoscopic or radiographic evaluation. Diagnosis and treatment of peptic ulcer disease and its compli- cations in the excluded stomach becomes difficult. We present a case of perforation in the bypassed stomach following LRYGBP secondary to peptic ulcer disease. Key words: Bypassed stomach, peptic ulcer, perforation, bariatric surgery, morbid obesity, laparoscopic Roux-en-Y gastric bypass Introduction Refractory morbid obesity is a major health problem in the United States, affecting 5% of the adult pop- ulation. 1 Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has become a popular operation to treat morbid obesity in USA, since the description of the technique by Wittgrove and Clark in 1994. 2 The fate of the bypassed stomach has been a problem for sur- geons since the era of open gastric bypass. A rare complication of RYGBP is perforation in the excluded stomach. The open-RYGBP literature reports a bypassed stomach perforation rate of <0.26%. 3 We report a case of bypassed stomach per- foration because of peptic ulcer disease following a LRYGBP. Case Report A 35-year-old female with a history of morbid obe- sity (BMI 45 kg/m 2 ) underwent LRYGBP. The patient had a history of iron deficiency anemia, which had been treated with oral iron and a proton pump inhibitor. A work-up for the anemia was neg- ative before the operation; it included upper and lower endoscopies, a small bowel follow-through contrast study and a nuclear scintigraphy scan. Six months following the LRYGBP the patient experienced an episode of dizziness and passed a small amount of bright red blood per rectum. Repeat upper and lower endoscopies were negative for any source of bleeding, and the gastric pouch appeared normal. The endoscopist was unable to access and visualize the bypassed stomach. The gas- trointestinal (GI) bleeding resolved without any fur- ther interventions. Six months later the patient developed acute onset of left upper quadrant pain, substernal chest pain and shortness of breath. An upright chest film demonstrated free air under the left hemi- diaphragm. The patient was taken emergently to the operating-room for an exploratory laparotomy, which revealed a perforated ulcer in the bypassed stomach. The perforation was located along the lat- eral aspect in the greater curvature, away from any previous staple-line. A partial gastrectomy was per- formed in order to remove the perforated segment. The patient had a stable postoperative course and was discharged home on the fifth postoperative day. Case Report Perforation in the Bypassed Stomach following Laparoscopic Roux-en-Y Gastric Bypass Pavlos K. Papasavas, MD; Woodrow W.Yeaney, MD; Philip F. Caushaj, MD; Robert J. Keenan, MD; Rodney J. Landreneau, MD; Daniel J. Gagné, MD Minimally Invasive Surgical Program,West Penn Allegheny Health System, Pittsburgh, PA, USA Reprint requests to: Daniel Gagné, MD, West Penn Hospital, Dept. of Surgery, 4800 Friendship Ave., Pittsburgh, PA 15224, USA. Fax: (412) 578-1434; e-mail: dgagne@wpahs.org