Marginal ulcers are a known complication after Roux-en-Y Gastric Bypass with an incidence ranging from 0.6 to 16%. Most patients respond well to medical therapy. On the contrary, a small subset will be refractory or present with an associated fistula requiring surgical intervention. In this video, we review the operative technique of a robotic gastrectomy and esophagojejunostomy for refractory marginal ulcers in a patient with a previous Roux-en-Y Gastric Bypass.


Video with verbal narration.


The patient was a 53-year-old female with a past medical history of hypothyroidism and gastroesophageal reflux, and past surgical history of Roux-en-Y Gastric Bypass (1991), abdominal panniculectomy, small bowel resection and hiatal hernia repair, and cholecystectomy. The patient consulted for intense and persistent abdominal pain associated with nausea and vomiting. She was diagnosed with a marginal ulcer 2 years ago and did not respond to medical therapy. An upper endoscopy and gastrointestinal series confirmed the diagnosis and excluded other complications. Surgery was indicated. Initial exploration showed massive adhesions involving the liver, gastric pouch, and excluded stomach. The gastric pouch was fused to the excluded stomach. The gastric pouch, gastrojejunostomy, and the proximal excluded stomach were resected. A side-to-side esophagojejunostomy was constructed. The patient tolerated well the procedure and was discharged on postoperative day 2.


Marginal ulcers are potentially complex complications following Roux-en-Y Gastric Bypass. A subset of patients will eventually be required surgical intervention after failed medical therapy. Revision of the gastrojejunostomy and total/subtotal gastrectomy are valid options.