Obesity stands as a prominent health challenge in our society, with metabolic bariatric surgery (MBS) emerging as a solution due to its efficacy in addressing obesity-related type 2 diabetes mellitus (T2DM). Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB) remain the most common MBS after sleeve gastrectomy. Complications from RYGB are uncommon but include anastomotic stricture, marginal ulcers, small bowel obstruction, and nutritional complications. We present a 52-year-old lady with an initial body mass index (BMI) of 27.6 kg/m2 and poorly controlled T2DM who presented with generalized body weakness and uncontrolled weight loss after an RYGB performed four months earlier. She was cachexic with a BMI of 17 kg/m2,with generalized anasarca with a multitude of electrolyte disturbances. After nutritional optimization, she underwent a reversal surgery back to normal anatomy. Reversal of RYGB to normal anatomy is a complex surgical procedure and is often the last resort undertaken in patients experiencing severe complications from the initial surgery. Indications include malnutrition, severe dumping syndrome, excessive weight loss, and recalcitrant marginal ulcers. Our case outlines the importance of proper patient selection for MBS and highlights the preoperative management of RYGB reversal to normal anatomy. We also describe the surgical procedure using a stepwise approach. In conclusion, the reversal of RYGB to normal anatomy should only be undertaken after a careful period of prehabilitation to reduce perioperative complications. The inclusion of dietitians, endocrinologists, and physiotherapists is crucial to ensure the best possible outcome.
Oesophagogastric junction carcinoma is now being increasingly regarded as a distinct site of neoplasia, separate from its adjacent sites. Recent advances in multimodal treatment approaches, including endoscopic procedures, oesophagectomy with three-field lymph node dissection, and definitive chemoradiotherapy, have significantly improved overall patient survival rates. Despite these advancements, the recurrence rate remains around 50% within one to three years following initial surgery. A major challenge in management arises when the resected surgical margins are involved with cancer. We present a 55-year-old man who experienced progressive dysphagia and, upon further assessment, was noted to have a Siewert III oesophagogastric junction adenocarcinoma. He underwent neoadjuvant chemotherapy before undergoing total gastrectomy with D2 lymphadenectomy with a Roux-en-Y reconstruction. Histopathological examination of the resected specimen revealed a positive proximal margin involvement. After optimization, he then underwent a salvage three-field McKeown oesophagectomy with colonic conduit reconstruction and adjuvant chemotherapy. Salvage surgery can be considered for patients with locoregional recurrence after definitive chemoradiotherapy or surgery. Other options include salvage chemoradiotherapy. Our case outlines the importance of proper patient selection for salvage surgery and highlights the choices of conduit in patients undergoing total esophagectomy post gastrectomy. In conclusion, managing proximal margin involvement of cardioesophageal junction adenocarcinoma remains a complex and multifaceted challenge, necessitating a tailored, multidisciplinary approach. The decision-making process must consider the patient's functional status, previous treatments, and specific anatomical considerations.