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CHRONIC NAUSEA AFTER ROUX-EN-Y GASTRIC BYPASS SUCCESSFULLY TREATED WITH PYLOROPLASTY OF THE REMNANT STOMACH
Tianyu Shang
*, Carla N. Holcomb
Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
Introduction: Chronic nausea and vomiting can be a challenging problem in patients following roux-en-y gastric bypass(RYGB). Gastroparesis of the remnant stomach can be responsible for these symptoms but is difficult to diagnose, as gastric emptying studies are not feasible of the remnant stomach. CT imaging demonstrating a dilated gastric remnant can help to make the diagnosis. Percutaneous gastrostomy tube and remnant gastrectomy have been utilized to treat this condition but do have associated morbidity to the patient. This report presents a case of remnant stomach gastroparesis treated successfully with robotic-assisted pyloroplasty.
Case Description:A 51-year-old female presented with chronic postprandial nausea, vomiting, and bloating two years after RYGB. Her medical history included two failed Nissen fundoplications, with GERD as the indication for RYGB. Despite extensive evaluations at an outside institution—including endoscopy, manometry, barium swallow, and CT imaging—the only notable finding was a mildly dilated gastric remnant (Figures 1 & 2). Given her history of revisional foregut surgeries, gastroparesis of the remnant stomach secondary to vagal nerve injury was suspected. The patient was taken to the operating room for transgastric endoscopy and robotic pyloroplasty. The transgastric endoscopy was performed by placing a 15mm port through the abdominal wall and into the remnant stomach. Endoscopy showed no abnormalities other than a tighted appearance of the pylorus. A standard Heineke-Mikulicz pyloroplasty was performed that included a 5cm longitudinal gastroduodenostomy that was closed vertically in two layers. An endoscopic air leak test was negative. There were no complications and the patient was discharged from the hospital on postoperative day one. At two- and six-week follow-up appointments, her symptoms of postprandial nausea, vomiting, and bloating had resolved entirely.
Discussion:This case underscores the role of remnant stomach gastroparesis as a potential cause of persistent nausea in post-RYGB patients with inconclusive workups. While previous studies have addressed gastroparesis of the remnant stomach with gastrostomy tubes or remnant gastrectomy, pyloroplasty has not been previously reported for this condition. Robotic-assisted pyloroplasty may present a viable, lower-morbidity alternative to traditional interventions, broadening therapeutic options for managing this complex condition.
Figure 1. Axial view of dilated gastric remnant
Figure 2. Coronal view of dilated gastric remnant
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