Hepatic Abscess in Inflammatory Bowel Disease: A Systematic Scoping Review of an Overlooked Entity.

Background: Liver abscess is one of the hepatobiliary manifestations of inflammatory bowel disease (IBD) that has been scarcely described in the literature. Objectives: To conduct a scoping review to provide a detailed description of the occurrence of hepatic abscess in patients with IBD and summarize the observed clinical features. Methodology: Searches were carried out using relevant keywords in Medline (via PubMed) and Web of Science from inception until June 13, 2022. Only articles that reported the occurrence of hepatic abscess in patients with IBD were included. Results: Forty-eight publications (40 case reports and 8 case series) were included, representing 73 patients with IBD who were radiologically or intraoperatively diagnosed with hepatic abscess. Patients with Crohn's disease were more predisposed to developing hepatic abscess than patients with ulcerative colitis (79.5% vs. 20.5%, respectively). Furthermore, pyogenic liver abscess was found to be more prevalent (57.9%) compared with aseptic (38.7%) and amebic (3.2%) abscesses. No clear relation was found between death or prolonged hospital stay in terms of the clinical presentation or management plan, as mortality was reported in different age groups with different managements. Conclusion: To date, there is no consensus regarding the appropriate management of hepatic abscess as an extraintestinal manifestation of IBD. However, the condition shares several features with liver abscess diagnosed among the general population.

Giant Sclerosing Hepatic Hemangioma Presenting as Bornman-Terblanche-Blumgart Syndrome: a Case Report and Review of the Literature.

Background: Hepatic hemangioma represents the most frequent benign tumor originating from the liver. When the tumor exceeds 10 cm, and in some studies 4 or 5 cm, it is considered giant, which accounts for 10% of all hemangiomas arising from the liver. Histologically, Sclerosing hepatic hemangioma, in particular, is an exceedingly rare subtype of hemangioma. Clinically Bornman-Terblanche-Blumgart syndrome is a very rare complication of hepatic hemangioma. Objective: The aim of this case presentation was to contribute to the literature by documenting a case of giant sclerosing hemangioma diagnosed in a 36-year-old female presenting with Bornman-Terblanche-Blumgart syndrome, along with a brief review of the literature. Case report: The current paper documents two rare clinical and histological features of hepatic hemangioma. Bornman-Terblanche-Blumgart syndrome is complicated a giant hepatic hemangioma found histologically to be sclerosing in nature. Knowledge about the uncommon complications of liver hemangioma permits the implementation of appropriate interventions in a timely manner and, in turn, can enhance the patient's quality of life and minimize rates of associated mortality.

Emergency versus elective cholecystectomy: Experience at a university hospital in the Eastern Province, Saudi Arabia.

BACKGROUND: Laparoscopic cholecystectomy (LC), the procedure of choice for treating most gallbladder pathology, has become the most trusted elective procedure for treating gallstone disease because of its effectiveness and safety. While the timing is an important factor in those cases, our aim in this study was to compare emergency and elective LC, determine the differences in postoperative complications, and assess the conversion rate to open cholecystectomy. MATERIALS AND METHODS: This study included a total of 627 patients who had undergone laparoscopic cholecystectomy during 2017-2019 at King Fahd Hospital of the University (KFHU). Records of both emergency and elective cases were reviewed from Quadra-med (software package). All demographic data of the patients, presenting complaint, laboratory and inflammatory marker, type of the operation, intraoperative complications, procedure time, conversion rate from laparoscopic to open cholecystectomy, postoperative period, length of hospital stay, and pathological diagnosis were entered into an Excel sheet. The data was analyzed using SPSS 23.0. Qualitative variables were described as frequencies and percentages, and continuous variables were summarized with mean and standard deviation (SD). Chi-square test, t-test, and the Mann-Whitney U-test were applied to test for statistical significance at P ≤ 0.05. RESULTS: The mean age for patients undergoing elective LC was 39.94 years (SD=13.56) whereas, mean age of patients undergoing emergency LC was 40.64 years (SD=13.02). About 71% of cases in elective LC group were females compared to 55% in the emergency LC group. There was a significant difference in C-reactive protein (CRP) in relation to the type of surgery where P < 0.05. Twelve (1.9%) patients had subtotal cholecystectomy and two cases converted from LC to open. There was a significant association between postoperative complication and the type of surgery. The length of hospital stay (LOS) was also found to be significantly more in patients having emergency LC (6.0 vs. 4.5 d; P < 0.05). CONCLUSION: The relation between conversion to an open procedure and type of surgery (elective or emergency) in our study was nonsignificant. There was a significant association between preoperative CRP, postoperative complication, length of hospital stay, and type of surgery. Further multicenter studies are required for further investigation.

Risk Factors and Surgical Outcomes of Diabetic Foot in Diabetic Patients at King Fahad University Hospital.

BACKGROUND: Diabetes mellitus affects a large number of the population worldwide. One of the most important complications is diabetic foot ulcers, which are debilitating to the patient and the health care system. OBJECTIVES: To assess the risk factors leading to diabetic foot complications and the surgical outcome of management of patients affected by diabetic foot at King Fahd University Hospital. METHODS: This is a retrospective case series study conducted at King Fahd University Hospital. The study included 52 patients who were admitted from the period 2007 to 2017 with cases of diabetic foot ulcers. The study includes a review of medical charts for diabetic foot patients including demographics, diabetic profile, associated comorbidities, clinical signs, laboratory investigations and surgical outcome. RESULTS: Our study shows that diabetic foot patients had comorbidities like hypertension at 69.2% and hyperlipidemia at 55.8%. Regarding the association between comorbidities and surgical outcomes, we did not find any significance. Furthermore, we found that patients with gangrene were more likely to undergo amputation. Patients who underwent amputation had hemoglobin A1c (HbA1c) of 10.3 ± 2.4% and random blood sugar (RBS) of 259 ±107 mg/dl, indicating poor diabetic control. CONCLUSION: Diabetic foot is the result of poor blood sugar control. Surgical intervention plays an important role in the management of diabetic foot. Depending on the presentation, patients may undergo surgical debridement, revascularization, or amputation. We found that patients who developed gangrene were more likely to undergo amputation.

Abdominal cocoon syndrome (idiopathic sclerosing encapsulating peritonitis): An extremely rare cause of small bowel obstruction-Two case reports and a review of literature.

Introduction: Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction in which the bowel and internal abdominal organs are wrapped with a fibrocollagenous cocoon-like encapsulating membrane [1,2]. SEP is divided into two entities: abdominal cocoons (AC), also known as idiopathic or primary sclerosing encapsulating peritonitis, which is of extremely rare type, and secondary sclerosing encapsulating peritonitis, which is the more common type. Case presentation: Two male patients from India, a 26 year old and a 36 year old, presented to our hospital complaining about abdominal pain associated with nausea and vomiting without any history of previous surgical interventions; the patients' vitals were stable. Preoperative diagnosis of abdominal cocoon was established by abdominal computed tomography. It showed multiple dilated fluid-filled small bowel loops in the center of the abdominal cavity with thin soft tissue, non-enhancing capsules encasing the small bowel loops with mesenteric congestion involving small and large bowel loops. Both patients underwent complete surgical excision of the sac without intraoperative complications. Patients had a smooth postoperative hospital course and were discharged home in good conditions. Conclusion: Patients with abdominal cocoons have a non-specific clinical presentation of intestinal obstruction. A high index of clinical suspicion in combination with the appropriate radiological investigation will increase the chance of preoperative detection of the abdominal cocoon. In patients with complete bowel obstruction, complete excision of the peritoneal sac is the standard of care.

Unusual ascites post laparoscopic cholecystectomy in old patient: Case report and review of the literature.

INTRODUCTION: Ascites that precede laparoscopic cholecystectomy is an infrequent event. Its actual mechanism is not identified, but an inflammatory or allergic peritoneal reaction has been proposed. It can a life-threatening or an acute serious condition; for instance, the bile duct or other visceral injuries are eliminated. CASE PRESENTATION: We present a 83 years old, medically free, who presented with fever and right upper quadrant pain. Diagnosed with severe acute calculus cholecystitis. Diagnostic laparoscopy and laparoscopic cholecystectomy were done, with copious irrigation of the abdomen. Postoperatively, patient started to had tense with moderate tenderness abdomen. Drain output showed clear ascites fluid. Postoperative ascites culture returned back as negative. Ascites treated conservatively with fluid restriction and furosemide. As per our knowledge, this is the fourth case that was reported in the literature of medicine. DISCUSSION: This was a particular case related to ascites which emerged without any known cause. The medical history of a powerful allergic background is can be the reason for transudative ascites that take place following an uneventful, occasional laparoscopic cholecystectomy. There was a presumed abnormal peritoneal or allergic reaction to the diathermy. No specific aetiological aspect was known irrespective of an extensive search being carried out. CONCLUSION: In cases of idiopathic post-laparoscopic ascites, general care and support is needed and fluid restriction and possible diuretic might be needed with no need for surgical intervention. Further studies are recommended for understanding of the pathophysiology of the disease.

Pleural Empyema as a Complication of Pyogenic Liver Abscess: Can the Minimum Achieve the Optimal? A Comparison of 3 Approaches.

BACKGROUND Pyogenic liver abscess is an uncommon entity that is potentially lethal. Pleural empyema and mediastinal collection are 2 rare complications of hepatic abscess that negatively impact the prognosis. CASE REPORT Herein, we report 3 cases of pyogenic liver abscesses complicated by pleural empyema, each approached differently, along with a succinct review of the literature. Case 1: A 29-year-old man diagnosed with Crohn's disease presented with Crohn's disease-associated hepatic abscess complicated by pleural empyema and concurrent mediastinal collection. The patient demonstrated significant improvement after administration of intrapleural fibrinolytic therapy. Case 2: A 42-year-old man with unremarkable past medical history presented with abdominal pain and dyspnea. Upon investigation, he was found to have massive pleural empyema secondary to liver abscess. In contrast to case 1, case 2 required pleural debridement via video-assisted thoracoscopic surgery followed by formal decortication through a posterolateral thoracotomy. Thereafter, a dramatic clinical improvement was observed. Case 3: A 26-year-old man with history of brucellosis 6 months before was transferred to our facility as a case of pleural empyema secondary to transdiaphragmatic extension of liver abscess. Unlike case 1 and 2, this patient was managed by drainage of hepatic and pleural collections under radiological guidance only, without the need for intrapleural fibrinolytic therapy or surgical intervention. CONCLUSIONS The current paper sheds light on one of the uncommon complications of hepatic abscess and contributes to this scant literature by summarizing pertinent publications. Adequate drainage remains the cornerstone of any pus collection management despite the complexity of some encountered cases.

Impact of wearing personal protective equipment on the performance and decision making of surgeons during the COVID-19 pandemic: An observational cross-sectional study.

ABSTRACT: During the coronavirus disease 2019 (COVID-19) pandemic, the mandatory use of personal protective equipment (PPE) has resulted in a significant reduction in the infection rate among health care workers (HCWs). However, there are some ongoing concerns about the negative impact of using PPE for prolonged periods.This study examined the impact of wearing PPE on surgeons' performance and decision making during the COVID-19 pandemic.In this cross-sectional study, an anonymous online questionnaire was created and disseminated to surgeons all over the Eastern Province of Saudi Arabia. The questionnaire included the demographic data, the local hospital policies, the non-technical skills (e.g., communication, vision, and comfort) and the technical skills, and the process of decision making.From June 2020 to August 2020, 162 surgeons participated in this questionnaire. Of them, 80.2% were aged from 26 to 45 years, 70.4% have received a special training for PPE, and 59.3% of participants have operated on COVID-19 confirmed cases. A negative impact of wearing PPE was reported on their overall comfort, vision, and communication skills (92.6%, 95.1%, and 82.8%, respectively). The technical skills and decision making were not significantly affected (60.5% and 72.8%, respectively). More preference for conservative approach, damage control procedures, and/or open approach was reported.Despite its benefits, PPE is associated with a significant negative impact on the non-technical skills (including vision, communication, and comfort) as well as a non-significant negative impact on technical skills and decision making of surgeons. Extra efforts should be directed to improve PPE, especially during lengthy pandemics.

Economic impact of diabetic foot ulcers on healthcare in Saudi Arabia: a retrospective study.

BACKGROUND: Diabetic foot ulcers (DFU) are a critical complication of diabetes mellitus (DM) affecting life quality and significantly impacting healthcare resources. OBJECTIVE: Determine the direct medical costs associated with treating DFU in King Fahad Hospital of the University and identify factors that could assist in developing resource management guidelines in Saudi Arabia. DESIGN: Retrospective study. SETTING: SETTING: King Fahad Hospital of the University, Al-Khobar, Saudi Arabia. PATIENTS AND METHODS: The study included diabetic patients admitted with foot ulcerations between 2007 and 2017 inclusive. We determined management costs including drug usage, wound dressings, surgical procedures, admissions, and basic investigation. MAIN OUTCOME MEASURES: Factors affecting the direct perspective medical costs of managing DFU. SAMPLE SIZE: 99 patients. RESULTS: The overall cost of managing 99 patients with DFU was 6 618 043.3 SAR ($1 764 632.68 USD), which further translates to approximately 6684.9 SAR per patient/year ($1782.6 USD). The highest cost incurred was for admission expenditure (45.6%), followed by debridement (14.5%) and intensive care unit (ICU) admission (10.4%). CONCLUSION: The overall healthcare expenditure in treating DFU is high, with hospital admissions and surgical procedures adding a significant increase to the total cost. Focused patient education on overall glycemic control and prevention of DFU may decrease complications and hence, the overall cost. LIMITATIONS: Identified only the direct medical costs of DFU as the indirect costs were subjective and more difficult to quantify. CONFLICT OF INTEREST: None.

Robotic versus laparoscopic distal pancreatectomy for left-sided pancreatic tumors: a single surgeon's experience of 228 consecutive cases.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) has gained popularity for the treatment of left-sided pancreatic tumors. Robotic systems represent the most recent advancement in minimally invasive surgical treatment for such tumors. Theoretically, robotic systems are considered to have several advantages over laparoscopic systems. However, there have been few studies comparing both systems in the treatment of distal pancreatectomy. We compared perioperative and oncological outcomes between the two treatment modalities. METHODS: A retrospective analysis was conducted of all consecutive minimally invasive distal pancreatectomy cases performed by a single surgeon at a high-volume center between January 2015 and December 2017. RESULTS: The analysis included 228 consecutive patients (LDP, n = 182; Robotic-assisted laparoscopic distal pancreatectomy [R-LDP], n = 46). Operative time was significantly longer in the R-LDP group than in the LDP group (166.4 vs. 140.7 min; p = 0.001). In a subgroup analysis of patients who underwent the spleen-preserving approach, the spleen preservation rate associated with R-LDP was significantly higher than that associated with LDP (96.8% vs. 82.5%; p = 0.02). In another subgroup analysis of patients with pancreatic cancer, there were no significant differences in median overall and disease-free survival between the two groups. CONCLUSIONS: R-LDP is a safe and feasible approach with perioperative and oncological outcomes comparable to those of LDP. R-LDP offers an added technical advantage that enables the surgeon to perform a complex procedure with good ergonomic comfort.

Propensity score-matching analysis comparing laparoscopic and open pancreaticoduodenectomy in elderly patients.

There is little evidence on the safety and benefits of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients; therefore, we evaluated the feasibility and efficacy of this procedure by comparing perioperative and oncological outcomes between LPD and open pancreaticoduodenectomy (OPD) in elderly patients. We retrospectively reviewed the data of 1,693 patients who underwent PD to manage periampullary tumours at a single institution between January 2014 and June 2017. Of these patients, 326 were elderly patients aged ≥70 years, with 56 patients allocated to the LPD group and 270 to the OPD group. One-to-one propensity score matching (56:56) was used to match the baseline characteristics of patients who underwent LPD and OPD. LPD was associated with significantly fewer clinically significant postoperative pancreatic fistulas (7.1% vs. 21.4%), fewer analgesic injections (10 vs. 15.6 times; p = 0.022), and longer operative time (321.8 vs. 268.5 minutes; p = 0.001) than OPD in elderly patients. There were no significant differences in 3-year overall and disease-free survival rates between the LPD and OPD groups. LPD had acceptable perioperative and oncological outcomes compared with OPD in elderly patients. LPD is a reliable treatment option for elderly patients with periampullary tumours.

Laparoscopic versus open pancreaticoduodenectomy for pancreatic neuroendocrine tumors: a single-center experience.

BACKGROUND: The efficacy and outcomes of laparoscopic resection for pancreatic neuroendocrine tumors (PNETs) are well established; however, specific data regarding the outcomes of laparoscopic pancreaticoduodenectomy (L-PD) are limited. The purpose of the present study was to compare the clinical and oncological outcomes following L-PD versus open PD (O-PD) in patients with PNETs. METHODS: This retrospective study included 149 patients with PNETs who underwent PD at the Asan Medical Center between January 2006 and December 2017. In 58 patients, a laparoscopic approach was used (L-PD group), and in 91, an open technique was used (O-PD group). RESULTS: The mean operative time was longer in the L-PD group than in the O-PD group (417.4 min vs. 362.2 min; p = 0.002), and the mean duration of postoperative stay was shorter in the L-PD group (12.6 days vs. 17.8 days; p < 0.001). The estimated blood loss (433.2 ml vs. 415.0 ml; p = 0.824) and the overall complication rate (34.5% vs. 38.5%; p = 0.624) did not significantly differ between the two groups. Regarding the oncological outcomes, there were no significant differences in the resection margins, tumor size, tumor grading, or T/N stage. The number of harvested lymph nodes in the L-PD group was lower than that in the O-PD group (7.1 vs. 10.8; p = 0.002). The 3-year overall survival rate was 91.9% in the L-PD group and 93.6% in the O-PD group (p = 0.974). The 3-year disease-free survival rate was 94.8% in the L-PD group and 86.7% in the O-PD group (p = 0.225). CONCLUSIONS: L-PD is feasible for the treatment of PNETs in selected patients and has the advantages of short recovery time and reduced hospital stay. The survival rate was similar in both groups; however, due to the difference in the harvested lymph nodes, a randomized trial should confirm the oncological safety of L-PD for PNETs.

Time-trend and recurrence analysis of pancreatic neuroendocrine tumors.

This study aimed to evaluate the evolving trends in clinicopathological features of pancreatic neuroendocrine tumors and to analyze the predictors of recurrence after curative resection. Data collected retrospectively from a single center between January 1990 and December 2017 were analyzed. Patients were categorized chronologically into three groups for evolving time-trend analysis. Overall, 542 patients (300 female, 55.4%) underwent surgical resection for pancreatic neuroendocrine tumors, including 435 (80.3%) with non-functional tumors. Time-trend analysis revealed that the surgically resected pancreatic neuroendocrine tumor number increased consistently; however, the incidental non-functional pancreatic neuroendocrine tumor number also increased over time (P < 0.001). The 5- and 10-year disease-free survival rates were 86.4 and 81.3%, respectively. The overall recurrence rate was 13.7%, and the most common site of recurrence was the liver. The median time to recurrence after primary surgery was 19.0 (range 0.8-236.3) months, and the median survival time after recurrence was 22.6 (range 0.4-126.9) months. On multivariate analysis, grade G3 pancreatic neuroendocrine tumors (hazard ratio 4.51; P < 0.001), lymph node metastasis (hazard ratio 2.46; P = 0.009), lymphovascular invasion (hazard ratio 3.62; P = 0.004), perineural invasion (hazard ratio 2.61; P = 0.004) and resection margin (hazard ratio 4.20; P = 0.003) were independent prognostic factors of disease-free survival. The surgically resected pancreatic neuroendocrine tumor number increased over time mainly because of an increase in incidentally discovered non-functional pancreatic neuroendocrine tumors. Grade G3 pancreatic neuroendocrine tumors, lymph node metastasis, lymphovascular invasion, perineural invasion and a positive resection margin were significant predictors of worse disease-free survival in patients with surgically resected pancreatic neuroendocrine tumors.

Prognostic Value of Adjuvant Chemotherapy Following Pancreaticoduodenectomy in Elderly Patients With Pancreatic Cancer.

BACKGROUND/AIM: The aim of this study was to investigate the relationship between age and long-term survival among patients who underwent pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS: A total of 916 patients who underwent PD for curative resection of PDAC were included in this study. Patients were divided into younger (n=726, <70 years) and older (n=190, ≥70 years), and the overall survival (OS) between the two groups was compared. RESULTS: Median OS was significantly longer in the younger group (p<0.001). However, the survival advantage among younger patients was not significant when analyzing only patients who received adjuvant chemotherapy (p=0.548). Among patients who did not receive adjuvant chemotherapy, OS was significantly longer in the younger group (p=0.003). Among patients who received neither adjuvant chemotherapy nor treatment for recurrence, survival was not significantly different between the groups (p=0.629). CONCLUSION: Adjuvant chemotherapy should be recommended, and additional treatment for recurrence is effective even among elderly who have not received adjuvant chemotherapy.

Cecal volvulus following mini gastric bypass: A case report and review of literature.

INTRODUCTION: With the rising worldwide obesity epidemic, bariatric surgeries are gaining popularity as the most effective modality for achieving long term results in weight loss and reducing its metabolic sequels. CASE PRESENTATION: A 36-year-old female presented with a sudden onset of severe abdominal pain for 6 h. The patient underwent Mini gastric bypass (MGB) 2 years prior to presentation. Computed tomography (CT) scan revealed a 14-cm dilatation of the cecum occupying the left upper quadrant of the abdomen with the swirling appearance of the mesentery. These findings were confirmed through emergency exploratory laparotomy to be cecal volvulus. a right hemicolectomy and conversion of MGB to a conventional Roux-en-Y gastric bypass. DISCUSSION: a modification of the classical gastric bypass surgery the MGB considered by its advocates to be a safer, simpler, and more effective option. However, serious complications can take place especially in the early learning curve of the procedure. CONCLUSIONS: We present a unexpected acute in top of chronic cecal volvulus in patient two years post MGB. The uncommon serious complication should be considered one of the differential diagnosis of acute surgical abdomen in those patients.

Acute intermittent porphyria after right hemi-colectomy.

INTRODUCTION: Acute intermittent porphyria is a rare autosomal dominant metabolic disease. It is caused by a genetic mutation that results in deficiency of porphobilinogen deaminase enzyme, the third enzyme in heme biosynthesis. Acute intermittent porphyria precipitated by surgery is very rare. CASE PRESENTATION: We present a 24 year-old woman who developed acute intermittent porphyria five days after right hemi-colectomy. Her presentation included neuro-visceral and psychiatric manifestations, and severe hyponatremia. She received critical care symptomatic management including mechanical ventilation. The diagnosis was based on a positive urine test for porphobilinogen and confirmed by the presence of a heterozygous mutation in the hydroxyrmethylbilane synthase (HMBS) gene (c.760delC p Leu254). DISCUSSION: Acute intermittent porphyria is the most common and life threatining type of acute porphyrias. It is more common in women and usually presents after puberty with acute abdominal pain and diverse neuro-psychiatric manifestations that can be confused with several surgical and medical diseases. Acute intermittent porphyria after surgery is most likely due to postoperative pain and low-calorie intake. Once suspected, prompt ICU management including high calorie intake are necessary to avoid serious complications and mortality before starting definitive treatment with hematin. CONCLUSION: Acute intermittent porphyria should be suspected in any patient, particularly young women, who develop diverse neuro-visceral and psychiatric manifestations and hyponatremia after surgery.

Hepaticojejunostomy for the management of sump syndrome arising from choledochoduodenostomy in a patient who underwent bariatric Roux-en-Y gastric bypass: A case report.

INTRODUCTION: Rapid weight loss following bariatric surgery is associated with high incidence of gallstones and complications that may need bilioenteric diversion. This presents a specific challenge in the management of this group of patients. CASE PRESENTATION: A 37 years old female underwent a Roux-en-Y gastric bypass (RYGB) in 2008 for morbid obesity. In 2009 she presented with obstructive jaundice and was diagnosed with choledocholithiasis successfully managed by open cholecystectomy and choledochoduodenostomy. In the following years, she developed recurrent attacks of fever, chills, jaundice, and right upper quadrant pain and her weight loss was not satisfactory. Imaging of the liver showed multiple cholangitic abscesses. Reflux at the choledochoduodenostomy site was suggestive of sump syndrome as a cause of her recurrent cholangitis and a definitive surgical treatment was indicated. Intraoperative findings confirmed sump at the choledochoduodenostomy site and also revealed the presence of a large superficial accessory duct arising from segment four of the liver with separate drainage into the duodenum distal to the choledochoduodenostomy site. A formal hepaticojejunostomy was done after ductoplasty. The Roux limb was created by transecting the jejunum 40cm distal to the foot anastomosis of the RYGB. The gastric limb was lengthened as part of this procedure which afforded the patient the additional benefit of weight loss. CONCLUSION: Choledochoduodenostomy should be avoided in patients with RYGB due to the risk of sump syndrome which requires conversion to a formal hepaticojejunostomy.