Image of the Month—Quiz Case FREE

A 38-YEAR-OLD white woman with a height of 167.6 cm and weight of 136.1 kg (body mass index, 48 [calculated as weight in kilograms divided by height in meters squared]) underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity. Comorbidities included dyslipidemia, osteoarthritis, urinary stress incontinence, and depression. Preoperative testing included endoscopy, which demonstrated grade III esophagitis. No gallstones were evident on abdominal ultrasound.

Laparoscopic RYGBP gastric bypass was performed without complications, and the patient's recovery was uneventful until postoperative day 2, when she developed sudden abdominal pain. An upper gastrointestinal series with oral contrast is shown in Figure 1. Although she remained afebrile and her urine output was adequate, she became tachycardic (120-130 beats/min) and complained of generalized abdominal pain. A computed tomographic scan of the abdomen with oral and intravenous contrast is shown in Figure 2.

A. Normal postoperative fluid from irrigation during laparoscopic RYGBP

B. Leakage at the gastrojejunal anastomosis

C. Biliopancreatic limb obstruction resulting in gastric staple line dehiscence

D. Leakage at the enteroenterostomy

Corresponding author: Arif Ahmad, MD, Department of Surgery, Stony Brook University Hospital, Health Sciences Center, Level 18, Room 60, Stony Brook, NY 11794-8191 (e-mail: ahmad@surg.som.sunysb.edu).