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Variations of the biliary system present challenges to abdominal operations and can affect postoperative outcomes. Bile leak is an uncommon complication of total gastrectomy. However, any procedure that involves mobilisation of the left lobes of the liver should be executed with additional caution. A thorough assessment including preoperative imaging for aberrant anatomy should be performed, especially aberrant bile ducts in the left triangular ligament. Ligation or suturing of the left triangular ligament should be considered when the aberrant anatomy suggests, to decrease the risk of postoperative bile leak. In addition, the left lateral segment of the liver should be thoroughly inspected on initial completion of the operation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Peliosis hepatis (PH) is an uncommon, benign hepatic vascular condition involving liver lesions consisting of dilated sinusoidal spaces that ultimately lead to numerous blood-filled cavities within the liver parenchyma. We detail the case of a 62-year-old woman who presented with a large hepatic haematoma resulting from intracystic haemorrhage. She was subsequently diagnosed with PH via arteriogram. Her symptoms were successfully treated surgically with open fenestration. Patient's postoperative course was unremarkable, with no recurrence of symptoms to date., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Gastrointestinal (GI) bleeding is a catastrophic complication of gastric bypass. Bleeding can occur during the early or late phase after the operation. Though bleeding after gastric bypass is infrequent, late bleeding is exceedingly rare. We present two patients with late bleeding following Roux-en-Y gastric bypass (RYGB). The first patient, a 65-year-old woman, presented with life-threatening upper GI bleeding almost 5 years after laparoscopic RYGB. The second patient, a 62-year-old woman, presented with upper GI bleeding after almost 14 years following RYGB. Both, due to an eroding marginal ulcer. We discuss here the management of a rare and catastrophic complication of late GI bleeding and review the various reports in the literature describing the late bleeding as a complication of gastric bypass. Late GI bleeding after RYGB presents a diagnostic and interventional challenge. High index of suspicion and adequate management strategies may lessen morbidity and mortality., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

An 84-year-old man presented with pancreatic adenocarcinoma. Following neoadjuvant chemoradiation, the patient underwent a pancreaticoduodenectomy, complicated by early bile leak. Re-exploration and intraoperative cholangiogram identified an accessory common bile duct draining segment 5 of the right hepatic lobe, which was then ligated. The patient underwent a complicated postoperative course eventually developing sepsis secondary to biliary stasis. He elected for comfort measures and passed away secondary to complications of sepsis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Ulcer perforation in the excluded stomach and duodenum is a rare complication after Roux-en-Y gastric bypass (RYGB). Pathogenesis of these ulcers are multifactorial. We report a case of perforated gastric remnant ulcer in a 54-year-old woman who had undergone a laparoscopic RYGB 5 years previously. The perforation was successfully repaired with an omental patch. We also present a review of the literature of similar cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)