Abstract
Background
The definition of marginal ulcer after Roux-en-Y gastric bypass (RYGB) is widely debated. This study reviewed findings of upper endoscopy in symptomatic patients at a quaternary bariatric referral center. Further investigation included symptom constellation, potential etiologies, and efficacy of treatment for patients found to have marginal ulcer.
Methods
Patients presenting for upper gastrointestinal endoscopy after Roux-en-Y gastric bypass were included in this study. An institutional review board-approved database was queried for the period 1 June 2010 to 31 August 2011. Subgroup analysis was performed for patients with marginal ulcer. Statistical analysis was performed using PASW version 18 for Windows.
Results
During the study period, 455 upper gastrointestinal endoscopies were performed for 328 consecutive symptomatic patients. Marginal ulcer, found in 112 patients (34 %), was diagnosed for 59 of the patients (53 %) within 12 months after surgery and for 53 of the patients (47 %) more than 12 months after surgery. In patients found to have marginal ulcer, the most common presenting symptoms were pain, dysphagia, nausea, and vomiting. All the patients with marginal ulcer underwent acid suppression and cytoprotective therapy. Using uni- and multivariate analyses for healing, nonhealing, and healing with recurrence, tobacco use was found to be the solitary significant risk factor for recurrence (p = 0.01).
Conclusion
Patients with pain or dysphagia after gastric bypass warrant upper endoscopy given the high yield for abnormalities. Although the risk factors for the development of marginal ulcer remain multifactorial, a thorough investigation for potential etiologies including tobacco, alcohol, and nonsteroidal antiinflammatory drug (NSAID) usage should be determined and eliminated. The presence of multiple risk factors may pose a higher challenge in ulcer resolution, leading to increased recurrence. In the current series, prior or current tobacco use remained the sole independent risk factor for ulcer persistence.
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References
Buchwald H, Oien DM (2009) Metabolic/bariatric surgery, worldwide 2008. Obes Surg 19:1605–1611
Dallal RM, Bailey LA (2006) Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis 2:455–459
Gumbs AA, Duffy AJ, Bell RL (2006) Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis 2:460–463
MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP (1997) Stomal ulcer after gastric bypass. J Am Coll Surg 185:1–7
Mason EE, Munns JR, Kealey GP, Wangler R, Clark WR, Cheng HF, Printen KJ (1976) Effect of gastric bypass on gastric secretion. Am J Surg 131:162–168
Patel RA, Brolin RE, Gandhi A (2009) Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 5:317–322
Printen KJ, Scott D, Mason EE (1980) Stomal ulcers after gastric bypass. Arch Surg 115:525–527
Rasmussen JJ, Fuller W, Ali MR (2007) Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc 21:1090–1094
Sapala JA, Wood MH, Sapala MA, Flake TM Jr (1998) Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 8:505–516
Schirmer B, Erenoglu C, Miller A (2002) Flexible endoscopy in the management of patients undergoing Roux-en-Y gastric bypass. Obes Surg 12:634–638
Huang CS, Forse RA, Jacobson BC, Farraye FA (2003) Endoscopic findings and their clinical correlations in patients with symptoms after gastric bypass surgery. Gastrointest Endosc 58:859–866
Wilson JA, Romagnuolo J, Byrne TK, Morgan K, Wilson FA (2006) Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol 101:2194–2199
Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC (2011) Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy 43:950–954
Csendes A, Burgos AM, Altuve J, Bonacic S (2009) Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg 19:135–138
Garrido AB Jr, Rossi M, Lima SE Jr, Brenner AS, Gomes CA Jr (2010) Early marginal ulcer following Roux-en-Y gastric bypass under proton pump inhibitor treatment: prospective multicentric study. Arq Gastroenterol 47:130–134
Csendes A, Torres J, Burgos AM (2011) Late marginal ulcers after gastric bypass for morbid obesity: clinical and endoscopic findings and response to treatment. Obes Surg 21:1319–1322
Behrns KE, Smith CD, Sarr MG (1994) Prospective evaluation of gastric acid secretion and cobalamin absorption following gastric bypass for clinically severe obesity. Dig Dis Sci 39:315–320
Herbella FA, Vicentine FP, Del Grande JC, Patti MG, Arasaki CH (2010) Postprandial proximal gastric acid pocket in patients after Roux-en-Y gastric bypass. J Gastrointest Surg 14:1742–1745
Hedberg J, Hedenstrom H, Nilsson S, Sundbom M, Gustavsson S (2005) Role of gastric acid in stomal ulcer after gastric bypass. Obes Surg 15:1375–1378
Hedberg J, Hedenstrom H, Sundbom M (2011) Wireless pH-metry at the gastrojejunostomy after Roux-en-Y gastric bypass: a novel use of the BRAVO system. Surg Endosc 25:2302–2307
Heneghan HM, Yimcharoen P, Brethauer SA, Kroh M, Chand B (2011) Influence of pouch and stoma size on weight loss after gastric bypass. Surg Obes Relat Dis. http://dx.doi.org/10.1016/j.soard.2011.09.010
Siilin H, Wanders A, Gustavsson S, Sundbom M (2005) The proximal gastric pouch invariably contains acid-producing parietal cells in Roux-en-Y gastric bypass. Obes Surg 15:771–777
Capella JF, Capella RF (1999) Gastrogastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 9:22–27 discussion 28
Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Villares A, Zundel N, Rosenthal R (2005) Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 1:467–474
Ben-Meir ASI, Patterson L, Schreiber H, Salomone M, Sharma K, Kumar A, Marshall J (2005) Cigarette smoking but not NSAID or alcohol use or comorbidities is associated with anastomotic ulcers in Roux-en-Y gastric bypass (RYGB) patients. Surg Obes Relat Dis 1:263–264
Pope GD, Goodney PP, Burchard KW, Proia RR, Olafsson A, Lacy BE, Burrows LJ (2002) Peptic ulcer/stricture after gastric bypass: a comparison of technique and acid suppression variables. Obes Surg 12:30–33
Sacks BC, Mattar SG, Qureshi FG, Eid GM, Collins JL, Barinas-Mitchell EJ, Schauer PR, Ramanathan RC (2006) Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2:11–16
Disclosures
B. Chand has served as a consultant and has received honoraria from Bard, Covidien, Ethicon, and Sanofi-Aventis. K. El-Hayek, P. Timratana, H. Shimizu have no conflicts of interest or financial ties to disclose.
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El-Hayek, K., Timratana, P., Shimizu, H. et al. Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned?. Surg Endosc 26, 2789–2796 (2012). https://doi.org/10.1007/s00464-012-2280-x
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DOI: https://doi.org/10.1007/s00464-012-2280-x