Right hemicolectomy combined with duodenum-jejunum Roux-en-Y anastomosis for hepatic colon carcinoma invading the duodenum:A single-center case series

BACKGROUND Hepatic colon carcinoma invading the duodenum is not common in clinical practice.Surgical treatment of colonic hepatic cancer that invades the duodenum is difficult,and the surgical risk is high.AIM To discuss the efficacy and safety of duodenum-jejunum Roux-en-Y anastomosis for the treatment of hepatic colon carcinoma invading the duodenum.METHODS From 2016 to 2020,11 patients from Panzhihua Central Hospital diagnosed with hepatic colon carcinoma were enrolled in this study.Clinical and therapeutic effects and prognostic indicators were retrospectively analyzed to determine the efficacy and safety of our surgical procedures.All patients underwent radical resection of right colon cancer combined with duodenum-jejunum Roux-en-Y anastomosis.RESULTS The median tumor size was 65 mm(r50-90).Major complications(ClavienDindoI-II)occurred in 3 patients(27.3%);the average length of hospital stay was 18.09±4.21 d;and only 1 patient(9.1%)was readmitted during the 1st mo after the surgery.The 30-d mortality rate was 0%.After a median follow-up of 41 m(r7-58),the disease-free survival at 1,2,and 3 years was 90.9%,90.9%and 75.8%,respectively;the overall survival at 1,2,and 3 years was 90.9%.CONCLUSION In selected patients,radical resection of right colon cancer combined with duodenum-jejunum Roux-en-Y anastomosis is clinically effective,and the complications are manageable.The surgical procedure also has an acceptable morbidity rate and mid-term survival.

Magnetic compression anastomosis for reconstruction of digestive tract after total gastrectomy in beagle model

BACKGROUND Magnetic compression anastomosis(MCA)is a simple procedure contributing to a reliable anastomosis.However,digestive-tract reconstruction after total gastrectomy using MCA has not yet been reported.AIM To investigate the feasibility of MCA for simultaneous esophagojejunostomy and jejunojejunostomy after total gastrectomy using beagle dogs.METHODS Sixteen beagles were randomly divided into an MCA group(study group,n=8)and a manual-suture anastomosis group(control group,n=8).Two different magnetic anastomosis devices were used in the study group for esophagojejunal and jejunojejunal anastomoses.Both devices included a pair of circular daughter and parent magnets each.The time of esophagojejunostomy and jejunojejunostomy,postoperative complications,and survival rate of the two groups were compared.The dogs were sacrificed one month after the operation and their anastomotic specimens were obtained.Healing was observed by the naked eye and a light microscope.RESULTS Digestive-tract reconstruction after total gastrectomy was successfully completed in both groups(survival rate=100%).In the study group,esophagojejunal and jejunojejunal anastomoses took 6.13±0.58 and 4.06±0.42 min,respectively,significantly lower than those in the control group(15.63±1.53 min,P<0.001 and 10.31±1.07 min,P<0.001,respectively).Complications such as bleeding,anastomotic leakage,and anastomotic stenosis were not observed.In the study group,the magnets did not interfere with each other.Discharge time of the jejunojejunal magnetic anastomosis device was 10.75±1.28 d,while that of the esophagojejunal magnetic anastomosis device was 12.25±1.49 d.Residual silk was found in the control group.The study group showed a greater smoothness of the anastomosis than that of the control group.All layers of anastomosis healed well in both groups.CONCLUSION MCA is a safe and feasible procedure for digestive-tract reconstruction after total gastrectomy in this animal model.

Passive-bending,short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients

AIM:To evaluate short-type-single-balloon enteroscope(SBE) with passive-bending,high-force transmission functions for endoscopic retrograde cholangiopancreatography(ERCP) in patients with Roux-en-Y anastomosis.METHODS:Short-type SBE with this technology(SIF-Y0004-V01; working length,1520 mm; channel diameter,3.2 mm) was used to perform 50 ERCP procedures in 37 patients with Roux-en-Y anastomosis.The rate of reaching the blind end,time required to reach the blind end,diagnostic and therapeutic success rates,and procedure time and complications were studied retrospectively and compared with the results of 34 sessions of ERCP performed using a short-type SBE without this technology(SIF-Y0004; working length,1520 mm; channel diameter,3.2 mm) in 25 patients.RESULTS:The rate of reaching the blind end was 90% with SIF-Y0004-V01 and 91% with SIF-Y0004(P = 0.59).The median time required to reach the papilla was significantly shorter with SIF-Y0004-V01 than with SIF-Y0004(16 min vs 24 min,P = 0.04).The diagnostic success rate was 93% with SIFY0004-V01 and 84% with SIF-Y0004(P = 0.17).The therapeutic success rate was 95% with SIF-Y0004-V01 and 96% with SIF-Y0004(P = 0.68).The median procedure time was 40 min with SIF-Y0004-V01 and 36 min with SIF-Y0004(P = 0.50).The incidence of hyperamylasemia was 6.0% in the SIF-Y0004-V01 group and 14.7% in the SIF-Y0004 group(P = 0.723).The incidence of pancreatitis was 0% in the SIFY0004-V01 group and 5.9% in the SIF-Y0004 group(P > 0.999).The incidence of gastrointestinal perforation was 2.0%(1/50) in the SIF-Y0004-V01 group and 2.9%(1/34) in the SIF-Y0004 group(P > 0.999).CONCLUSION:SIF-Y0004-V01 is useful for ERCP inpatients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.

Comparison between laparoscopic uncut Roux-en-Y and Billroth Ⅱ with Braun anastomosis after distal gastrectomy:A meta-analysis

BACKGROUND Conventional Billroth Ⅱ(BⅡ) anastomosis after laparoscopic distal gastrectomy(LDG) for gastric cancer(GC) is associated with bile reflux gastritis, and Roux-enY anastomosis is associated with Roux-Y stasis syndrome(RSS). The uncut Rouxen-Y(URY) gastrojejunostomy reduces these complications by blocking the entry of bile and pancreatic juice into the residual stomach and preserving the impulse originating from the duodenum, while BⅡ with Braun(BB) anastomosis reduces the postoperative biliary reflux without RSS. Therefore, the purpose of this study was to compare the efficacy and safety of laparoscopic URY with BB anastomosis in patients with GC who underwent radical distal gastrectomy.AIM To evaluate the value of URY in patients with GC.METHODS PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang, Chinese Biomedical Database, and VIP Database for Chinese Technical Periodicals(VIP) were used to search relevant studies published from January 1994 to August 18, 2021. The following databases were also used in our search: Clinicaltrials.gov, Data Archiving and Networked Services, the World Health Organization International Clinical Trials Registry Platform Search Portal(https://www.who.int/clinical-trials-registry-platform/the-ictrp-search-portal), the reference lists of articles and relevant conference proceedings in August 2021. In addition, we conducted a relevant search by Reference Citation Analysis(RCA)(https://www.referencecitationanalysis.com). We cited highquality references using its results analysis functionality. The methodological quality of the eligible randomized clinical trials(RCTs) was evaluated using the Cochrane Risk of Bias Tool, and the non-RCTs were evaluated using the Newcastle-Ottawa scale. Statistical analyses were performed using Review Manager(Version 5.4).RESULTS Eight studies involving 704 patients were included in this meta-analysis. The incidence of reflux gastritis [odds ratio = 0.07, 95% confidence interval(CI): 0.03-0.19, P < 0.00001] was significantly lower in the URY group than in the BB group. The pH of the postoperative gastric fluid was lower in the URY group than in the BB group at 1 d [mean difference(MD) =-2.03, 95%CI:(-2.73)-(-1.32),P < 0.00001] and 3 d [MD =-2.03, 95%CI:(-2.57)-(-2.03), P < 0.00001] after the operation. However,no significant difference in all the intraoperative outcomes was found between the two groups.CONCLUSION This work suggests that URY is superior to BB in gastrointestinal reconstruction after LDG when considering postoperative outcomes.

Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration

BACKGROUND Bilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown. AIM To explore the feasibility and effectiveness of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China. METHODS This is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated. RESULTS Forty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60 (93.8%) cases and successful diagnosis in 59 (92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation, and no post-ERCP pancreatitis occurred. CONCLUSION Based on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.

Novel method for esophagojejunal anastomosis after laparoscopic total gastrectomy:Semi-end-to-end anastomosis

AIM: To test a new safe and simple technique for circular-stapled esophagojejunostomy in laparoscopic total gastrectomy (LATG).

Proximal gastrectomy with jejunal interposition and TGRY anastomosis for proximal gastric cancer

AIM: To compare the short-term outcomes of patients who underwent proximal gastrectomy with jejunal interposition (PGJI) with those undergoing total gastrectomy with Roux-en-Y anastomosis (TGRY).

Transoral outlet reduction:Outcomes of endoscopic Roux-en-Y gastric bypass revision in 284 patients at a community practice

BACKGROUND Transoral outlet reduction(TORe)is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass(RYGB)for weight recurrence;however,little has been published on its clinical implementation in the community setting.AIM To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB.METHODS This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022.Patients were provided longitudinal nutritional support via virtual visits.The primary outcome was total body weight loss(TBWL)at twelve months from TORe.Secondary outcomes included TBWL at three months and six months;excess weight loss(EWL)at three,six,and twelve months;twelve-month TBWL by obesity class;predictors of twelve-month TBWL;rates of post-TORe stenosis;and serious adverse events(SAE).Outcomes were reported with descriptive statistics.RESULTS Two hundred eighty-four adults(91.9%female,age 51.3 years,body mass index 39.3 kg/m^(2))underwent TORe an average of 13.3 years after RYGB.Median pre-and post-TORe outlet diameter was 35 mm and 8 mm,respectively.TBWL was 11.7%±4.6%at three months,14.3%±6.3%at six months,and 17.3%±7.9%at twelve months.EWL was 38.4%±28.2%at three months,46.5%±35.4%at six months,and 53.5%±39.2%at twelve months.The number of follow-up visits attended was the strongest predictor of TBWL at twelve months(R^(2)=0.0139,P=0.0005).Outlet stenosis occurred in 11 patients(3.9%)and was successfully managed with endoscopic dilation.There was one instance of post-procedural nausea requiring overnight observation(SAE rate 0.4%).CONCLUSION When performed by an experienced endoscopist and combined with longitudinal nutritional support,purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB.

Comparison of long-term quality of life between Billroth-I and Roux-en-Y anastomosis after distal gastrectomy for gastric cancer: a randomized controlled trial

Background:The results of studies comparing Billroth-I(B-I)with Roux-en-Y(R-Y)reconstruction on the quality of life(QoL)are still inconsistent.The aim of this trial was to compare the long-term QoL of B-I with R-Y anastomosis after curative distal gastrectomy for gastric cancer.Methods:A total of 140 patients undergoing curative distal gastrectomy with D2 lymphadenectomy in West China Hospital,Sichuan University from May 2011 to May 2014 were randomly assigned to the B-I group(N=70)and R-Y group(N=70).The follow-up time points were 1,3,6,9,12,24,36,48,and 60 months after the operation.The final follow-up time was May 2019.The clinicopathological features,operative safety,postoperative recovery,long-term survival as well as QoL were compared,among which QoL score was the primary outcome.An intention-to-treat analysis was applied.Results:The baseline characteristics were comparable between the two groups.There were no statistically significant differences in terms of postoperative morbidity and mortality rates,and postoperative recovery between the two groups.Less estimated blood loss and shorter surgical duration were found in the B-I group.There were no statistically significant differences in 5-year overall survival(79%[55/70]of the B-I group vs.80%[56/70]of the R-Y group,P=0.966)and recurrence-free survival rates(79%[55/70]of the B-I group vs.78%[55/70]of the R-Y group,P=0.979)between the two groups.The scores of the global health status of the R-Y group were higher than those of the B-I group with statistically significant differences(postoperative 1 year:85.4±13.1 vs.88.8±16.1,P=0.033;postoperative 3 year:87.3±15.2 vs.92.8±11.3,P=0.028;postoperative 5 year:90.9±13.7 vs.96.4±5.6,P=0.010),and the reflux(postoperative 3 year:8.8±12.9 vs.2.8±5.3,P=0.001;postoperative 5 year:5.1±9.8 vs.1.8±4.7,P=0.033)and epigastric pain(postoperative 1 year:11.8±12.7 vs.6.1±8.8,P=0.008;postoperative 3 year:9.4±10.6 vs.4.6±7.9,P=0.006;postoperative 5 year:6.0±8.9 vs.2.7±4.6,P=0.022)were milder in the R-Y group than those of the B-I group at the postoperative 1,3,and 5-year time points.Conclusions:Compared with B-I group,R-Y reconstruction was associated with better long-term QoL by reducing reflux and epigastric pain,without changing survival outcomes.Trial Registration:ChiCTR.org.cn,ChiCTR-TRC-10001434.

Myoelectric activity and motility of the Roux limb after cut or uncut Roux-en-Y gastrojejunostomy

AIM: To explore the mechanisms of uncut Roux-en-Y gastrojejunostomy, which is used to decrease the occurrence of Roux stasis syndrome.METHODS: The changes of myoelectric activity, mechanic motility and interstitial cells of Cajal (ICC) of the Roux limb after cut or uncut Roux-en-Y gastrojejunostomy were observed. RESULTS: When compared with the cut group, the amplitude (1.15 ± 0.15 mV vs 0.48 ± 0.06 mV, P < 0.05) and frequency (14.4 ± 1.9 cpm vs 9.5 ± 1.1 cpm, P < 0.01) of slow waves and the incidence (98.2% ± 10.4% vs 56.6% ± 6.4%, P < 0.05) and amplitude (0.58 ± 0.08 mV vs 0.23 ± 0.06 mV, P < 0.01) of spike potential of the Roux limb in the uncut group were significantly higher. The migrating myoelectric complexes (MMC) phase Ⅲ duration in the uncut group was significantly prolonged (6.5 ± 1.1 min vs 4.4 ± 0.8 min, P < 0.05), while the MMC cycle obviously shortened (42.5 ± 6.8 vs 55.3 ± 8.2 min, P < 0.05). Both gastric emptying rate (65.5% ± 7.9% vs 49.3% ± 6.8%, P < 0.01) and intestinal impelling ratio (53.4% ± 7.4% vs 32.2% ± 5.4%, P < 0.01) in the uncut group were significantly increased. The contractile force index of the isolated jejunal segment in the uncut group was significantly higher (36.8 ± 5.1 vs 15.3 ± 2.2, P < 0.01), and the expression of c-kit mRNA was significantly increased in the uncut group (0.82 ± 0.11 vs 0.35 ± 0.06, P < 0.01). CONCLUSION: Uncut Roux-en-Y gastrojejunostomymay lessen the effects of operation on myoelectric activity such as slow waves, spike potential, and MMC, decrease the impairment of gastrointestinal motility, and remarkably increase the expression of c-kit mRNA.

Roux-en-Y choledochojejunostomy using novel magnetic compressive anastomats in canine model of obstructive jaundice

BACKGROUND:The traditional hand-sewn Roux-en-Y choledochojejunostomy is technically complicated,and the incidence of postoperative complications has remained high.A set of novel magnetic compressive anastomats was introduced to facilitate choledochojejunostomy and improve the prognosis of patients.METHODS:After ligating the common bile duct for 7 days,16 dogs were randomly divided into two groups (n=8 per group).Anastomats were used in the study group,and the traditional hand-sewn method was used in the control group for standard Roux-en-Y choledochojejunostomy.We compared the operation time,incidence of complications,gross appearance,and pathological disparity in stoma between the two groups in 1-month and 3-month follow-up examinations.RESULTS:The time spent on constructing the anastomosis for the study group was significantly shortened.Although no anastomotic stenosis occurred in the two groups,the narrowing rate of biliary-enteric anastomosis was much higher in the control group.There was one case of bile leakage in the control group,whereas no bile leakage occurred in the study group.A smoother surface,an improved layer apposition,and a lower local inflammatory response were identified in the anastomosis of the study group.CONCLUSION:The structures of the novel magnetic compressive anastomats are simple,and they are time-saving,safe and efficient for performing Roux-en-Y choledocho- jejunostomy procedures in a canine model of obstructive jaundice.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation

To evaluate risk factors of biliary anastomotic complications （BACs） and outcomes according to type of biliary reconstruction. METHODS： A total of 33 consecutive adult living donor liver transplantation （LDLT） were reviewed, 17 of which had undergone Duct-to-Duct anastomosis （D-D）. The remaining 16 patients received Roux-en-Y anastomosis （R-Y）. The perioperative factors, such as the type of graft and the number of graft bile ducts, were analyzed retrospectively. RESULTS： The overall incidence of BACs was 39.4%. The incidence of BACs was significantly higher in the patients with than without neoadjuvant chemotherapy （71.4% vs 10%, P = 0.050）. There was no significant difference in the incidence of biliary leakage in patients with D-D vs. those with R-Y. The incidence of biliary strictures following the healing of biliary leakage was significantly higher in D-D （60%） than in R-Y （0%） （P = 0.026）. However, the incidence of BACs related bacteremia was significantly higher in R-Y than in D-D （71.4% vs 0%, P = 0.008）. In D-D, use of T-tube stent remarkably reduced the incidence of 8ACs, compared with straight tube stent （0% vs 50%, P = 0.049）. CONCLUSION： Our experience showed an increase of BACs related bacteremia in the patients with R-Y. Therefore, D-D might be a preferred biliary reconstruction. However, the surgical refinement of D-D should be required because of the high incidence of biliary strictures. Use of the T-tube stent might lead to a significant reduction of BACs in D-D.

Diagnosis and treatment of congenital choledochal cyst: 20 years' experience in China

AIM: To summarize the experience of diagnosis and treatment of congenital choledochal cyst in the past 20 years (1980-2000). METHODS: The clinical data of 108 patients admitted from 1980 to 2000 were analyzed retrospectively. RESULTS: Abdominal pain,jaundice and abdominal mass were presented in most child cases. Clinical symptoms in adult cases were non-specific, resulting in delayed diagnosis frequently. Fifty-seven patients (52.7%) had coexistent pancreatiobiliary disease. Carcinoma of the biliary duct occurred in 18 patients (16.6%).Ultrasonic examination was undertaken in 94 cases, ERCP performed in 46 cases and CT in 71 cases. All of the cases were correctly diagnosed before operation. Abnormal pancreatobiliary duct junction was found in 39 patients. Before 1985 the diagnosis and classification of congenital choledochal cyst were established by ultrasonography preoperatively and confirmed during operation, the main procedures were internal drainage by cyst enterostomy. After 1985, the diagnosis was established by ERCP and CT, and cystectomy with Roux-en-Y hepaticojejunostomy was the conventional procedures.In 1994, we reported a new and simplified operative procedure in order to reduce the risk of choledochal cyst malignancy. Postoperative complication was mainly retrograde infection of biliary tract, which could be controlled by the administration of antibiotics, there was no perioperative mortality. CONCLUSION: The concept in diagnosis and treatment of congenital choledochal cyst has obviously been changed greatly.CT and ERCP were of great help in the classification of the disease.Currently, cystectomy with Roux-en-Y hepaticojejunostomy is strongly recommended as the choice for patients with type I and type IV cysts. Piggyback orthotopic liver transplantation is indicated in type V cysts (Caroli's disease) with frequently recurrent cholangitis.

Palliative operation procedures for pancreatic head carcinoma

Objective: To investigate the procedure choice of pal-liative operation for carcinoma of the head of the pan-creas (CHP).Methods: The clinical data from 187 patients withCHP treated in the last 20 years were analyzed retro-spectively.Results: The operation mortality rate was 8.6%, themortality of hepatic duct-jejunostomy (HDJS) was nothigher than that of cholecystojejunostomy (CJS) (P>0.05). The postoperative relapse of jaundice and cholan-gitis was significantly lower than that of CJS (P<0.025), while the survival was apparently higher thanthat of CJS (P<0.01). The mortality of HJDS or CJSwith gastrojejunostomy (GJS) was not significantlyhigher than that of the simple procedure without GJS(P>0.05), whereas the survival was significantlyhigher than that of the simple procedure without GJS(P<0.01). The occurrence of duodenal obstructionafter HDJS or CJS was 29.3%.Conclusion: As a palliative operation, Roux-en-Y chole-dochojejunostomy especially in combination with pre-ventive gastrojejunostomy is strongly recommended.

Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice.Recently,therapeutic endoscopic retrograde cholangiopancreatography(ERCP) using double-balloon enteroscopy(DBE) has been shown to be feasible and effective,even in patients with surgically altered anatomies.On the other hand,endoscopic partial stent-in-stent(PSIS) placement of selfexpandable metallic stents(SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible,safe and effective.We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success.This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization,even in patients with surgically altered anatomies.

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report

BACKGROUND Roux-en-Y gastric bypass(RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis(GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation(APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.CASE SUMMARY A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA.Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel.Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.CONCLUSION APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.