Identification and management of an errant antiperistaltic Roux limb after total gastrectomy

We recently evaluated two patients because of persistent, unexplained bilious vomiting following total gastrectomy with Roux-en-Y esophagojejunostomy. With the aid of intestinal manometry and reoperation, an antiperistaltic Roux limb was discovered in both cases. Isoperistaltic repositioning of the Roux limb led to resolution of both patients' symptoms. These case reports illustrate the devastating consequences of a poorly constructed Roux-en-Y esophagojejunostomy and demonstrate the utility of intestinal manometry in aiding the diagnosis of problems related to the Roux limb, particularly when surgical reexploration is not preferred or is inconclusive. By highlighting this avoidable technical error, we hope to prevent its future occurrence.