RESUMO
With the growing obesity epidemic, surgeons are performing more bariatric surgeries, including Roux-en-Y gastric bypass (RYGB) reversals. Although studies have identified indications for RYGB reversals, little information is available about the long-term effects of the procedure. We wish to highlight a case with long-term complications of RYGB reversal and subsequent management. We present a patient with multiple abdominal surgeries including an RYGB reversal that was complicated by a stenosed gastrogastric anastomosis that caused several gastrojejunostomy ulcerations and malnutrition secondary to intractable nausea and vomiting. A 51-year-old female with a complex surgical history including a simple RYGB reversal in 2019 presented to the ER with complaints of abdominal pain, uncontrolled diarrhea, and an inability to tolerate food for six months. Workup revealed multiple marginal ulcers at the remnant jejunum attached to the gastric pouch, and a stenosed gastrogastrostomy placed high along the cardia of the remnant stomach and pouch. This stenosis resulted in a nonfunctional, nondependent reversal that only drained when filled. Ultimately, a large gastrotomy was performed, and an endoscope was utilized to identify a small pinhole connection between the patient's pouch and the remnant stomach along the superomedial portion of the remnant stomach's fundus. The anvil of a 60 mm GIA black load stapler was guided through and fired twice to come across the stricture. After the stricture was completely crossed, the endoscope was passed through, confirming that it was widely patent. The postoperative course was uneventful, and the patient was discharged with total parenteral nutrition (TPN) on postoperative day 15 before being discontinued at her follow-up visit. She reported that she had been gaining weight and eating well. Long-term complications following RYGB reversal are not well-discussed in the literature. This case offers insight into such complications, discusses the surgical technique utilized to fix them, and calls for further research on the topic to better inform surgeons and patients alike.
RESUMO
Traumatic ballistic injury is an unfortunate and commonly encountered problem seen by surgeons. An estimated 85,694 nonfatal ballistic injuries occur annually, and in 2020 there were 45,222 firearm-related deaths in the United States. Surgeons of all subspecialties may provide necessary care. Acute care injuries are generally reported to authorities immediately; however, delayed presentation of ballistic injuries may go unreported despite regulations to do so. We present a case of a delayed ballistic injury and a comparative review of individual states' reporting requirements to highlight statutory obligations and penalties as an educational reference for surgeons treating ballistic injuries. Methods: Google and PubMed searches were performed utilizing keywords "ballistic," "gunshot," "physician," and "reporting" as terms. Inclusion criteria included the English language, official state statute sites, legal and scientific articles, and websites. Exclusion criteria included nongovernmental sites and information sources. Data collected were analyzed to include statute numbers, time to report, infraction consequences, and monetary fines. The resultant data are reported by state and region. Results: All but two state jurisdictions mandate healthcare providers to report knowledge and/or treatment of ballistic injuries, regardless of the timeline of injury. Violations of mandatory reporting may lead to fines or imprisonment, depending on the specific state. The timeline for reporting, fines, and subsequent legal action varies by state and region. Conclusions: Requirements for reporting injuries exist in 48 of 50 states. The treating physician/surgeon should thoughtfully question patients with a chronic ballistic injury history and provide reports to local law enforcement.