约翰尼哈达德博士，溃疡穿孔

A 32 year old male patient presented to our hospital for acute epigastric pain. Patient underwent laparoscopic mini gastric bypass in our center 6 months ago, he is a heavy smoker and a social drinker, he is on multivitamins calcium and iron as per our center protocol.
A diagnosis of perforated gastrojejunal anastomotic ulcer was suspected and confirmed by abdominal CT scanner. After a failed trial of conservative management for 48 hours . A diagnostic laparoscopy was decided . A perforation in the gastrojejunostomy was found and suture repaired. On Day two post operatively a gastrographin swallow showed proper sealing and patient was started on oral feeding. Drains were removed and he was discharged on long term double dose proton pump inhibitor on the fourth day. He received proper smoking and alcohol cessation counseling.
Mini gastric bypass is a relatively young procedure; recently Chevalier reported 2 cases of perforation in 1000 mini gastric bypass performed, they were treated with laparotomy and T tube drainage, both cases were heavy smokers.
Our case highlights the deleterious effect of smoking on anastomotic ulcer pathogenesis, and the role of early diagnostic laparoscopy and repair in optimal conditions as well as the indication of conservative management in the setting of post bariatric surgery perforated ulcer.

                               
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