Journal of Medical Case Reports and Case Series ISSN: 2692-988

Case Report Volume 4 Issue 05

Case Study of a chronically Obese Smoker With S/P RYGB Complications of Intussusception,
Incisional Hernia, and Marginal Ulcers.
Javairia Ayyub1*, Sailaja Nandennagari2, Preethi Annam2, Vimal R. Basani3, Raiza Singh3, Ahmad Al shhraifeen4,
Frederic M Tiesenga5
1
Caribbean Medical University School of Medicine, Curaçao
2
Avalon University School of Medicine, Curaçao
3
St. George’s University School of Medicine
4
The Hashemite University School of Medicine, Jordan
5
Community First Medical Center
*Corresponding Author: Javairia Ayyub, Caribbean Medical University School of Medicine, Curaçao.
Received date: 08 March 2023; Accepted date: 28 March 2023; Published date: 10 April 2023
Citation: Ayyub J, Nandennagari S, Annam P, Basani VR, Singh R, et al. (2023) Case Study of A Chronically Obese Smoker With S/P RYGB
Complications of Intussusception, Incisional Hernia, and Marginal Ulcers. J Med Case Rep Case Series 4(05):
https://doi.org/10.38207/JMCRCS/2023/APR04050431
Copyright: © 2023 Javairia Ayyub. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract
Objective:
This case study aimed to highlight all the complications of status post Roux-en-Y/Gastric bypass in a chronically obese smoker the following
year.
Background:
Roux-en-Y gastric bypass (RYGB) is considered one of the most successful procedures with a low mortality rate for bariatric surgery in morbidly
obese patients. However, it can lead to complications like marginal ulcer, volvulus, internal hernia, intussusception, cholelithiasis, and gastro-
gastric fistula with varied morbidity.
Presentation:
A 62-year-old female patient with a past surgical history of Roux-en-Y gastric bypass with hiatal hernia repair presented mid-epigastric pain
and dysphagia and developed several complications like intussusception and incisional ulcer, followed by gastrojejunal marginal ulcer within
few months after the gastric bypass surgery. A computed tomography scan and EGD were performed to confirm the diagnosis.
Discussion:
Intussusception is a rare complication of RYGB, accounting for ≅1% of small bowel obstruction cases. Although the risk factors for the
development of marginal ulcers remain multifactorial, smoking remains the primary factor causing recurrence. Computerized tomography scan
and EGD represents the diagnostic test of choice. Early surgical intervention may prevent the possibility of bowel resection.
Conclusion:
This case demonstrates the presence of a triad of intussusception, incisional ulcer, and marginal ulcer in a chronic smoker, which was managed
by initial reduction followed by limited surgical resection.
Keywords: Gastric bypass, intussusception, marginal ulcer, incisional ulcer, etc.

Background:
RYGB has gained popularity among bariatric and laparoscopic most common procedures for morbid obesity, this minimally invasive
surgeons due to its highly successful method in weight loss in patients procedure poses risks [12]. This paper discusses complications,
with morbid obesity. RYGB is a weight-reducing procedure that including intussusception, incisional hernia, and a marginal ulcer in
entails creating a small pouch from the stomach's lesser curvature and a single patient following a Roux-en-Y gastric bypass surgery after
connecting it to the small intestine [7]. Even though this is one of the the primary lap band failed.

Introduction
Roux-en-Y gastric bypass (RYGB) is considered one of the gold documented and should not be overlooked. One of the most common
standard procedures for bariatric surgery in morbidly obese patients. complications is marginal ulcers which carry the risk of severe
However, the complications associated with this procedure are well- morbidity and mortality due to the possibility of perforation and

Citation: Ayyub J, Nandennagari S, Annam P, Basani VR, Singh R, et al. (2023) Case Study of A Chronically Obese Smoker With S/P RYGB Complications of Intussusception, Incisional Hernia, and Marginal
Ulcers. J Med Case Rep Case Series 4(05): https://doi.org/10.38207/JMCRCS/2023/APR04050431
 Journal of Medical Case Reports and Case Series ISSN: 2692-988
heavy bleeding. Unfortunately, the etiology of these ulcers is still Intussusception is the rarer cause of SBO, with the incidence of small
unknown; however, several risk factors have been identified, such as bowel intussusception after gastric bypass surgery estimated to be
a history of type 2 diabetes and peptic ulcers [6,8]. Other well-known between 0.1 and 1.2 % [9,11]. However, due to the recent surge in the
complications of RYGB include small bowel obstruction (SBO), popularity of bariatric surgery as a tool for weight loss management,
which can be due to intussusception, internal hernia, and volvulus. the overall incidence of intussusception post-op has also increased.

Case Details
As a result of revisionary Roux-en-Y gastric bypass surgery with Assessment:
hiatal hernia repair, a 62-year-old Caucasian female smoker develops Initially, a CT scan confirmed the diagnosis of JJ intussusception.
multiple complications months after the surgery. She is a chronic Later, a CT scan was used again to confirm the diagnosis of incisional
smoker who smokes ten cigarettes daily, uses medicinal marijuana, hernia. Jejuno-Jejunal (J-J) intussusception and incisional hernia
and drinks alcohol occasionally. Before her gastric bypass, she had a were planned to be repaired, one after the other, respectively, in
laparoscopic gastric band in 2021, which was later removed due to subsequent visits. Later, EGD was ordered to evaluate marginal ulcers
complications. After swallowing, the patient initially complained of as a part of the preoperative workup, and labs and vitals were
intermittent epigastric pressure, which eventually subsided with PPIs. monitored. Risks, benefits, and alternatives were discussed with the
However, the patient continued to have intermittent epigastric and patient in detail, and the patient acknowledged the same.
abdominal pain and acid reflux for a few months post-surgery. After
Management:
eating, she complained of epigastric pain with pressure, vomiting, and
The patient had Roux-en-Y gastric bypass with hiatal hernia repair
acidity. The patient has a medical history of arthritis, GERD, morbid
done on 01/11/222, followed by complaints of having occasional mid-
obesity, lumbar disc disorder, depressive disorder, hiatal hernia, and
abdominal pain and bloating, which worsened over time. An
nephrolithiasis. Due to her continued experience of symptoms of
abdominal CT scan revealed a minuscule infraumbilical ventral
mid-epigastric pain, lower abdominal pain, bloating and occasional
abdominal wall hernia and an enormous stool burden. On 12/11/2022,
vomiting after certain foods, the patient was diagnosed with a small
intussusception was repaired by initial reduction followed by limited
infraumbilical ventral abdominal wall hernia, which was surgically
surgical resection. EGD was done, revealing a gastrojejunal marginal
repaired later in 2022. To summarize, she has a surgical history of
ulcer without hemorrhage or perforation, but the surgical intervention
left nephrectomy on 01/01/1987, and the left kidney was donated to
was unnecessary. On 01/16/23, the patient had a new complaint of
her daughter; cholecystectomy (1990), hip/knee Surgery (2013),
abdominal pain and emesis, leading to an incisional hernia diagnosis.
laparoscopic gastric band (2015), laparoscopy with adhesiolysis
The patient was counseled about smoking cessation as Smoking
(09/27/2016), bladder surgery (12/28/2016 & 01/04/2017),
increases the risk of ulcers, hernia, and recurrence, but the patient
esophagogastroduodenoscopy (10/11/2021), and lap band removal
was not receptive to this discussion. On 01/24/23, Incarcerated
(11/11/2021).
incisional hernia repair was done successfully. On 02/06/23, the
Physical Exam on arrival: patient complained of having epigastric pain and abdominal
· Abdomen: Large Pannus, normal bowel sounds, slightly tender discomfort post incisional hernia repair on 01/24/23. The patient was
small Incisional Hernia, no masses feeling better but refused to stop smoking.
· Constitutional: Ambulation with a cane. During all fourteen follow-up visits she had till today, we can observe
· Head: Normocephalic and atraumatic weight loss of 66 lbs. and BMI reduced from 33.8 to 21.1 kg/sq meter.
· Lungs: Clear to auscultation and percussion, no dyspnea, rales, Following is the list of medications the patient used for her past
wheezing medical problems and current medical conditions, and she claims she
· Musculoskeletal: No cyanosis, varicosities, or lower extremity adheres to the medications as per the prescription and was allergic to
edema, right leg with a brace Lyrica.
· Neurologic: No tremor, oriented to time, place, and person Aleve, Amitriptyline, Aripiprazole, Bevespi Aerosphere inhaler,
· Psychiatric: everyday mood and affect, active and alert Celebrex, Chantix, Diclofenac, Esomeprazole, Furosemide, Incruse
· Skin: No rash or jaundice, good turgor Ellipta, Meloxicam, Morphine, Oxybutynin, Oxycodone,
Pantoprazole, Tylenol-Codeine, Duloxetine, Propranolol, Trintellix,
and Famotidine.
Discussion
There are several bariatric surgeries, from less invasive to more become a prominent method to treat morbid obesity lately. However,
invasive such as laparoscopic gastric band, gastric sleeve, and gastric many factors limit patients from having bariatric procedures or
bypass. Whether the procedure is invasive or non-invasive, it has causing complications. Although these complications could occur in

Citation: Ayyub J, Nandennagari S, Annam P, Basani VR, Singh R, et al. (2023) Case Study of A Chronically Obese Smoker With S/P RYGB Complications of Intussusception, Incisional Hernia, and Marginal
Ulcers. J Med Case Rep Case Series 4(05): https://doi.org/10.38207/JMCRCS/2023/APR04050431
 Journal of Medical Case Reports and Case Series ISSN: 2692-988
caused by the prolapse of intracavitary structures, such as a segment
patients after Roux-en-Y gastric bypass (RYGB), it is rare to have
of the small intestine, through the trocar orifice. Typically,
multiple complications seen in the same patient. In our case, the
ultrasonography and physical examination are preferred methods to
patient presented with intussusception, incisional hernia, and
diagnose incisional hernia. A CT scan confirmed the patient's
marginal ulcer within one year after revisional Roux-en-Y gastric
incisional hernia and intermittent symptoms of lower abdominal pain
bypass (RYGB). Prior to the procedure, the patient had a removal of
with protrusion of the hernia [1]. A marginal ulcer is one of the most
the laparoscopic gastric band, which was her first bariatric surgery.
common complications that could occur after Roux-en-Y gastric
Contributing factors that could cause multiple complications in our
bypass (RYGB), especially in patients who smoke. Studies show that
patient is chronic smoking and failed lap gastric band prior to Roux-
after analyzing different causes of the ulcer, tobacco use was the
en-Y gastric bypass (RYGB). Study shows that patients who
solitary significant risk factor for recurrence (p = 0.01) [10]. Despite
underwent revisional Roux-en-Y gastric bypass (RYGB) after lap
being aware of marginal ulcers due to smoking, our patient smoked
gastric band removal instead of a primary procedure tend to have a
ten cigarettes/per day throughout her procedures. EGD was
higher risk of complications [2]. It is well-documented that gastric
performed to confirm the diagnosis. The patient presents epigastric
bypass surgeries have approximately 0.1-0.3 % chance of a Jejuno-
pain, pressure, and dysphagia throughout the 2022 post-gastric
Jejunal (JJ) intussusception complication, as seen in our patient who
bypass. Although intake of NSAIDS, alcohol, and smoking are all
suffered from intermittent abdominal pain post-procedure for months
risk factors for causing marginal ulcers, tobacco remains the most
without relief despite taking medicine [4]. Incisional hernia is
crucial risk factor that causes marginal ulcers, delays their healing,
another complication observed in our patient, which was later
and causes recurrence.
repaired. It is characterized by a protrusion of the abdominal wall

Conclusion
lab bands contribute to the risk of developing complications, smoking
Our patient's case report illustrates multiple rare complications of
at any magnitude is associated with a very high risk of developing
RYGB, like intussusception, marginal ulcer, and incisional ulcer, all
marginal ulcers after RYGB, and therefore smoking cessation before
in a single patient presenting with symptoms of constant epigastric
and after bariatric surgery is highly recommended.
abdominal pain. Although alcohol, NSAIDs, and failure of previous

Funding: No funding received.

Authors Contributions:
All the authors in this paper contributed as per our discussion as Abbreviations:
follows, JA and SN together contributed case details and discussion, ED: Emergency Department
Vimal to Introduction, Raiza to Background, and Ahmad helped in EGD: Esophagogastroduodenoscopy
discussion. AP contributed to abstracting and concluding along with
GERD: Gastroesophageal Reflux Disease
active participation in acquiring any case details. Thank you to Dr.
JJ Anastomosis: Jejuno-Jejunal Anastomosis
Frederick M. Tisienga for helping us in this paper. Without his
NSAIDS: Non-Steroidal Anti-Inflammatory Drugs
guidance and support, this would not have been possible.
PPI: Proton Pump Inhibitors
Patient Consent To Publish: Patient’s written consent was
obtained. RYGB: Roux-en-Y Gastric Bypass

Conflict of Interest To Publish: Authors declare no conflict of SBO: Small Bowel Obstruction
interest to this work. SpO2: Oxygen Saturation
Peer Review: External peer review done.

References
3. Marcoe JP, Chau WY (2021) Intussusception after open Roux-en-
1. Rossi FMB, Moreno R, Druziani AL, Perez MM, Possari E, et al.
Y gastric bypass managed with laparoscopic reduction. J Surg
(2022) INCISIONAL HERNIA AFTER BARIATRIC
Case Rep. 2021(8): rjab339.
SURGERY: ONLY THE PHYSICAL EXAMINATION IS
4. Al Sulaiti MA, Darwish A, Al Khalifa K (2019) Intussusception
ENOUGH? Arquivos Brasileiros de Cirurgia Digestiva: ABCD =
after laparoscopic one anastomosis gastric bypass: A rare
Brazilian Archives of Digestive Surgery. 35: e1673.
complication. International Journal of Surgery Case Reports. 60:
2. Gonzalez-Urquijo M, Hinojosa-Gonzalez DE, Gidi AGA,
270–272.
Hurtado Arellano S, Flores-Villalba E, et al. (2021) Revisional
5. Wang E, Blackham R, Tan J, Hamdorf J (2017) Giant perforated
Roux-en-Y gastric bypass after failed gastric banding: a case-
marginal ulcer after laparoscopic Roux-en-Y gastric bypass. BMJ
matched study. Surgical Endoscopy. 36(7): 4815-4820.
Case Reports. 2017: bcr2016218829.

Citation: Ayyub J, Nandennagari S, Annam P, Basani VR, Singh R, et al. (2023) Case Study of A Chronically Obese Smoker With S/P RYGB Complications of Intussusception, Incisional Hernia, and Marginal
Ulcers. J Med Case Rep Case Series 4(05): https://doi.org/10.38207/JMCRCS/2023/APR04050431
 Journal of Medical Case Reports and Case Series ISSN: 2692-988
6. Sverdén E, Mattsson F, Sondén A, Leinsköld T, Tao W, et al. Surgery for Obesity and Related Diseases: Official Journal of the
(2016) Risk Factors for Marginal Ulcer After Gastric Bypass American Society for Bariatric Surgery. 9(5): 725–730.
Surgery for Obesity. Annals of Surgery. 263(4): 733–737. 10. El-Hayek K, Timratana P, Shimizu H, Chand B (2012) Marginal
7. Abdeen G, le Roux C (2015) Mechanism Underlying the Weight ulcer after Roux-en-Y gastric bypass: what have we really
Loss and Complications of Roux-en-Y Gastric Bypass. Review. learned? Surgical Endoscopy. 26(10): 2789–2796.
Obesity Surgery. 26(2): 410–421. 11. Simper SC, Erzinger JM, McKinlay RD, Smith SC (2008)
8. Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Retrograde (reverse) jejunal intussusception might not be such a
Wagensveld BA (2014) Development of Ulcer Disease After rare problem: a single group’s experience of 23 cases. Surgery for
Roux-en-Y Gastric Bypass, Incidence, Risk Factors, and Patient Obesity and Related Diseases: Official Journal of the American
Presentation: A Systematic Review. Obesity Surgery. 24(2): 299– Society for Bariatric Surgery. 4(2): 77–83.
309. 12. Higa KD, Boone KB, Ho T (2000) Complications of the
9. Varban O, Ardestani A, Azagury D, Lautz DB, Vernon AH, et al. Laparoscopic Roux-en-Y Gastric Bypass: 1,040 Patients - What
(2013) Resection or reduction? The dilemma of managing Have We Learned? Obesity Surgery. 10(6): 509–513.
retrograde intussusception after Roux-en-Y gastric bypass.

Citation: Ayyub J, Nandennagari S, Annam P, Basani VR, Singh R, et al. (2023) Case Study of A Chronically Obese Smoker With S/P RYGB Complications of Intussusception, Incisional Hernia, and Marginal
Ulcers. J Med Case Rep Case Series 4(05): https://doi.org/10.38207/JMCRCS/2023/APR04050431