Late Presentation of a Perforated Marginal Ulcer Three Years After Mini Gastric Bypass: A Rare Entity

Marginal ulcers (MUs) are an uncommon complication following one-anastomosis gastric bypass (OAGB). They are often managed conservatively, but in some cases, they can progress to perforation. Such ulcer-related perforations are particularly rare and usually occur early in the postoperative period. We report the case of a middle-aged woman who presented with sudden, severe abdominal pain several years after undergoing OAGB. She had no identifiable active risk factors. Abdominal X-ray showed free air under the diaphragm, and computed tomography (CT) scan demonstrated extraluminal air and contrast near the gastrojejunostomy, findings interpreted as suspicious for perforation at the anastomotic site. Diagnostic laparoscopy confirmed a perforated marginal ulcer (PMU) at the anastomotic site, with the anastomosis itself remaining intact. The diagnosis was made intraoperatively based on visual inspection, revealing an ulcer at the anastomotic site with an apex measuring approximately 1.5 cm. No biopsy was obtained, as the ulcer margins appeared benign with no evidence of ischemia or malignancy. The defect was repaired with a laparoscopic Graham's patch and omentopexy. The patient recovered well and returned to normal activity shortly after discharge. This case is notable for its delayed presentation, progression of a marginal ulcer to perforation at the gastrojejunal anastomosis, and the absence of additional modifiable risk factors apart from the inherent risk associated with the anastomosis itself. It underscores the importance of maintaining a high index of suspicion for late complications in post-bariatric patients and shows that timely minimally invasive surgery can achieve excellent outcomes.