45 year old woman with prior laparoscopic retrocolic antegastric Roux-en-Y gastric bypass (RYGB) with complications of recurrent perforated marginal ulcers, revision to esophagojejunostomy, presented with several months bile reflux and emesis. Upper gastrointestinal series was negative, upper endoscopy found bile pooling in gastric pouch and roux limb, and HIDA scan did not show retrograde flow. At laparoscopic exploration, we were unable to find a gastrogastric fistula after taking down minimal adhesions. As we could not explain her bile within the roux limb, it was decided to lengthen her 100 cm roux limb. After stapling off the biliopancreatic limb from the jejunojejunostomy and dividing the mesentery, a fistula was found from the biliopancreatic limb to the roux limb at the transverse mesocolic space. This was likely due to the closure of this potential space during the creation the retrocolic passage of the roux limb. This fistula was then stapled off and a new jejunojejunostomy, was then created distal to the prior site. Postoperatively, the patient was discharged on day 1, and had no further bile reflux at follow ups.
Bile reflux after RYGB is rare however usually attributed to short roux limb, gastrogastric fistula, or Roux-en-O configuration. This the first reported case of a biliopancreatic fistula to the roux limb causing unexplained bile reflux after Roux-en-Y gastric bypass. Standard workup with imaging was unable to detect the fistula, and after surgical exploration and dissection of the jejunostomy, the fistula was found.