Background: Total gastrectomy with Roux-en-Y esophagojejunostomy is a standard surgical treatment for gastric cancer. While internal hernias are known complications following Roux reconstructions, hiatal herniation of the biliopancreatic (afferent/duodenal) limb is exceptionally rare. Only a few cases have been described in the literature. We present a case of intrathoracic herniation of the duodenal limb causing obstructive symptoms 10 months after total gastrectomy.

Case presentation: A 70-year-old woman with a history of locally advanced gastric cancer treated with neoadjuvant chemotherapy underwent total laparoscopic gastrectomy with Roux-en-Y reconstruction 10 months before presentation. She presented with progressive abdominal pain and unintentional weight loss over one month. Physical examination revealed mild epigastric tenderness without signs of peritonitis. Laboratory results were unremarkable. Contrast-enhanced CT revealed a markedly dilated duodenal (biliopancreatic) limb filled with fluid, herniating through the esophageal hiatus into the thoracic cavity, findings consistent with afferent limb obstruction due to hiatal herniation. An upper endoscopy was performed in an attempt to decompress and reduce the limb. Although endoscopic detorsion has been reported to be successful in selected cases of Roux limb obstruction post-gastrectomy, in this patient, the afferent limb was fixed within the hiatus, and reduction was not possible. After that, the patient was under surgical intervention. A laparoscopic approach was attempted and revealed a grossly dilated afferent limb incarcerated at the hiatus. A hernia detorsion was not possible due to gentle manipulation, so needle decompression with aspiration of enteric contents was performed, allowing successful reduction of the limb back into the abdomen. The hiatal defect was repaired, and no intestinal resection was required. The patient recovered uneventfully and was discharged on postoperative day 10.

Conclusion: Hiatal herniation of the biliopancreatic limb is a rare but important cause of small bowel obstruction following total gastrectomy with Roux-en-Y reconstruction. Non-specific symptoms such as abdominal pain and weight loss may delay diagnosis. In post-gastrectomy patients presenting with such symptoms, even months after surgery, clinicians should consider this entity in the differential diagnosis. Prompt surgical reduction and defect repair can avoid severe complications, provide good outcomes, and prevent further morbidity.