Abstract
BACKGROUND: Ischemic necrosis of the gastric remnant following Roux-en-Y gastric bypass (RYGB) surgery is a rare but life-threatening complication. The etiology remains poorly understood, and delayed presentation can result in poor outcomes. Prompt recognition and intervention are critical, particularly in patients with a remote history of bariatric surgery. CASE REPORT: A 78-year-old male (body mass index 28.73 kg/m(2)) with a history of RYGB performed 42 years prior presented to the emergency department with nausea, diffuse abdominal pain, and signs of septic shock. Physical examination revealed abdominal distension, peritonitis, tachycardia, and hypotension. Laboratory findings showed elevated lactate and lipase levels. Imaging demonstrated a dilated gastric remnant and free intra-abdominal fluid. Emergent exploratory laparotomy identified a necrotic gastric remnant, necessitating remnant gastrectomy. The patient initially stabilized postoperatively but developed pneumonia on postoperative day 6, followed by a duodenal stump leak. Despite conservative management, his condition deteriorated, and comfort care measures were initiated. He died on postoperative day 13. CONCLUSION: This case highlights the importance of maintaining a high index of suspicion for rare complications such as gastric remnant necrosis in patients with a history of RYGB and a low threshold for surgical exploration. Timely diagnosis and surgical intervention are essential for improving outcomes in these critically ill patients.