Necrotic Excluded Gastric Remnant Post Gastric Bypass: A Rare Fatal Complication

We report an unusual case of a 76-year-old woman with a necrotic perforated excluded gastric pouch who had stomach partitioning gastrojejunostomy 20 years earlier for morbid obesity. The necrotic mucosa of the excluded gastric pouch was seen on gastroscopy with retrograde cannulation from the pylorus. Laparotomy revealed a distended excluded stomach with full-thickness ischaemia of the posterior wall with perforation into the lesser sac. Partial gastrectomy with Roux-en-Y gastrojejunostomy was performed. We strongly suggest early surgical exploration for these patients when they are hemodynamically unstable or do not have a precise diagnosis despite imaging to prevent potentially life-threatening gastric pouch necrosis. We advocate for avoiding risk factors like alcohol, nicotine, and nonsteroidal anti-inflammatory drugs (NSAIDs) and implement preoperative Helicobacter pylori testing and its eradication to reduce the incidence of perforation in the excluded pouch.