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1
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Vosburg RW, Nimeri A, Azagury D, Grover B, Noria S, Papasavas P, Carter J. ASMBS literature review on the treatment of marginal ulcers after metabolic and bariatric surgery. Surg Obes Relat Dis 2025; 21:1-8. [PMID: 39516065 DOI: 10.1016/j.soard.2024.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Accepted: 10/05/2024] [Indexed: 11/16/2024]
Abstract
Marginal ulcers (MUs) encompass a group of mucosal disruptions and subsequent inflammatory changes and their sequala found after Roux-en-Y gastric bypass (RYGB) oneanastomosis gastric bypass (OAGB), and, less commonly, after biliopancreatic diversion with duodenal switch (BPD/DS) or single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). Prevalence of MU after RYGB ranges from .6%-16%. This review summarizes the current knowledge about the treatment options available for MU after MBS for providers who treat them.
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Affiliation(s)
| | | | - Dan Azagury
- Stanford School of Medicine, Palo Alto, California
| | | | - Sabrena Noria
- The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | | | - Jonathan Carter
- University of California, San Francisco, San Francisco, California
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2
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Jazi AHD, Mehrnia N, Teimoury T, Shahmiri SS. Simultaneous Occurrence of Two Perforated Marginal Ulcer After Roux-en-Y Gastric Bypass Without Any Risk Factor. Obes Surg 2024; 34:3140-3141. [PMID: 38965188 DOI: 10.1007/s11695-024-07375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Amir Hossein Davarpanah Jazi
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Minimally Invasive Surgery Research Center, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nariman Mehrnia
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Taher Teimoury
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Minimally Invasive Surgery Research Center, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shahab Shahabi Shahmiri
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Minimally Invasive Surgery Research Center, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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3
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Pfeifer N, Steffen T, Vines LC, Folie P. Late marginal ulcer perforation after Roux-en-Y Gastric bypass - A case report with two-step management. Int J Surg Case Rep 2024; 119:109720. [PMID: 38714069 PMCID: PMC11096734 DOI: 10.1016/j.ijscr.2024.109720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/09/2024] Open
Abstract
INTRODUCTION Marginal ulcers are an acid-related complication of laparoscopic Roux-en-Y gastric bypass. Few cases of acute perforation have been described, and there are few reports on viable surgical management. This case report demonstrates a two-step surgical procedure for treating a perforated late marginal ulcer in a patient with sepsis. PRESENTATION OF CASE A 39-year-old smoker presented to the emergency department six years after undergoing a Roux-en-Y gastric bypass. Diagnostic findings revealed ascites and changes in intestinal calibre, indicating the need for surgery. Intraoperatively, a perforated marginal ulcer covered by the liver was observed. Given the extent of the perforation and the patient's increased instability, discontinuity resection was performed. After stabilisation and improvement in the nutritional status, the gastrojejunostomy was restored nine weeks later. DISCUSSION Treatment of Marginal ulcers is controversial, with no clear guidelines. However, severe complications require endoscopic or surgical treatment. The literature considers three main surgical treatment options for perforated marginal ulcers: surgical repair, surgical anastomotic revision, and gastric bypass reversal. Complicated situations, significant intraoperative findings, and unstable patients require tailored approaches. CONCLUSION A two-step procedure with discontinuity resection for damage control surgery, patient stabilisation, and improvement of nutritional status, followed by elective continuity restoration with a new gastrojejunostomy, is considered feasible in critically ill patients.
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Affiliation(s)
- Nina Pfeifer
- Department of General, Visceral, Endocrine and Transplant Surgery & Bariatric Surgery Center of Eastern Switzerland, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
| | - Thomas Steffen
- Department of General, Visceral, Endocrine and Transplant Surgery & Bariatric Surgery Center of Eastern Switzerland, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
| | | | - Patrick Folie
- Department of General, Visceral, Endocrine and Transplant Surgery & Bariatric Surgery Center of Eastern Switzerland, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
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4
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Pope R, English W, Walden RL, Bradley E, Spann M, Ardila-Gatas J, Broucek J, Williams B, Samuels JM. Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series. Am Surg 2024; 90:810-818. [PMID: 37927010 DOI: 10.1177/00031348231209533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Perforated marginal ulcers (PMUs) are a rare but known complication of bariatric surgery. Management typically involves prompt surgical intervention, but limited data exists on non-operative approaches. This study reviews published data on non-operative management of PMUs and presents a case series of patients who were managed non-operatively. Our hypothesis is that certain patients with signs of perforation can be successfully managed non-operatively with close observation. METHODS We completed a systematic review searching PubMed, Embase, Web of Science, Cochrane, and clinicaltrials.gov. Ultimately 3 studies described the presentation and non-operative management of 5 patients. Additionally, we prospectively collected data from our institution on all patients who presented between Dec. 2022 and Dec. 2023 with PMUs confirmed on imaging and managed non-operatively. RESULTS In our literature review, three patients had Roux-en-Y gastric bypass (RYGB), while two had one anastomosis gastric bypass. One patient required surgery two days after admission. Another underwent elective conversion surgery weeks later for a non-healing ulcer. Two received endoscopic interventions. One patient recovered with nil-per-os (NPO) status, and intravenous proton pump inhibitor (PPI) treatment. The patients in our case series presented with normal vital signs, an average of 30 months after RYGB, and with CT scan signs of perforation. None of these patients required surgical or endoscopic intervention. CONCLUSION In conclusion, while perforated marginal ulcers have traditionally been considered a surgical emergency, some patients can be successfully treated with non-operative management. More research is needed to identify the clinical presentation features, comorbidities, and imaging findings of this group.
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Affiliation(s)
- Rand Pope
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wayne English
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rachel L Walden
- Eskind Biomedical Library, Vanderbilt University, Nashville, TN, USA
| | - Emma Bradley
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Spann
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica Ardila-Gatas
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph Broucek
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brandon Williams
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason M Samuels
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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5
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Salame M, Jawhar N, Belluzzi A, Al-Kordi M, Storm AC, Abu Dayyeh BK, Ghanem OM. Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management. J Clin Med 2023; 12:4336. [PMID: 37445371 DOI: 10.3390/jcm12134336] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.
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Affiliation(s)
- Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Noura Jawhar
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Amanda Belluzzi
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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6
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Altieri MS, Rogers A, Afaneh C, Moustarah F, Grover BT, Khorgami Z, Eisenberg D. Bariatric Emergencies for the General Surgeon. Surg Obes Relat Dis 2023; 19:421-433. [PMID: 37024348 DOI: 10.1016/j.soard.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 02/04/2023] [Indexed: 02/16/2023]
Affiliation(s)
- Maria S Altieri
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Ann Rogers
- Department of Surgery, Hershey School of Medicine, Penn State University, Hershey, Pennsylvania
| | | | - Fady Moustarah
- Department of Surgery, Beaumont Hospital, Bloomfield Hills, Michigan
| | - Brandon T Grover
- Department of Surgery, Gundersen Lutheran Medical Center, La Crosse, Wisconsin
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma College of Community Medicine, Tulsa, Oklahoma; Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Dan Eisenberg
- Department of Surgery, Stanford School of Medicine and VA Palo Alto Health Care System, Palo Alto, California
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7
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Crawford CB, Schuh LM, Inman MM. Revision Gastrojejunostomy Versus Suturing With and Without Omental Patch for Perforated Marginal Ulcer Treatment After Roux-en-Y Gastric Bypass. J Gastrointest Surg 2023; 27:1-6. [PMID: 36131200 DOI: 10.1007/s11605-022-05461-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/10/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulceration at the gastrojejunostomy is a late bariatric surgery complication in 0.6-16% of Roux-en-Y gastric bypass (RYGB) patients. As there is no general consensus on management of acute ulcer perforations, we compare two methods of surgical repair: the most commonly performed procedure, suturing of ulcer with or without omental patch versus revision gastrojejunostomy (RG). METHODS A retrospective chart review of cases at a single large, Midwestern US high-volume bariatric center from November 2, 2006 through March 11, 2021 identified 144 RYGB patients undergoing surgical repair for a perforated ulcer: 72 treated by SGP and 72 by RG. Outcomes, including length of stay, leaks, readmissions, and reoperations, were compared. Categorical variables were compared by Chi-square tests and continuous variables by ANOVA. RESULTS Patients were primarily female (77.1%) and Caucasian (97.2%), 49.7 ± 12.5 years old, and 90.6 ± 26.6 kg. Most had laparoscopic RYGBs (98.6%). There were no demographic differences between groups. Of the RG patients, 11.4% experienced ulcer recurrence versus 41.7% of SGP patients (p < .001), and 2.8% of RG versus 11.1% of SGP patients required a reversal (p < .05). No significant differences between groups occurred in time to perforation (3.2 vs. 2.5 years for RG and SGP groups, respectively), length of stay (5.0 vs. 6.8 days), leaks (1.4% vs. 2.8%), readmissions (4.2% vs. 4.2%), or reoperations (2.8% vs 5.6%). CONCLUSIONS Patients developing perforated marginal ulcers after RYGB can be safely and effectively treated by revision gastrojejunostomy with a lower likelihood of ulcer recurrence. Short-term morbidity was comparable to suturing with or without an omental patch.
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Affiliation(s)
- Christopher B Crawford
- Meridian Surgical Group, 13430 N. Meridian St, Suite 275, Carmel, IN, 46032, USA. .,Ascension St. Vincent Bariatrics, Carmel, IN, 46032, USA.
| | - Leslie M Schuh
- Ascension St. Vincent Bariatrics, Carmel, IN, 46032, USA
| | - Margaret M Inman
- Meridian Surgical Group, 13430 N. Meridian St, Suite 275, Carmel, IN, 46032, USA.,Ascension St. Vincent Bariatrics, Carmel, IN, 46032, USA
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8
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Wynn M, Tecson KM, Provost D. Marginal ulcers and associated risk factors after Roux-en-Y gastric bypass. Proc AMIA Symp 2023; 36:171-177. [PMID: 36876264 PMCID: PMC9980672 DOI: 10.1080/08998280.2022.2137362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
As the prevalence of morbid obesity continues to climb in America, so does the popularity of the Roux-en-Y gastric bypass (RYGB) to achieve weight loss goals; however, a long-term risk of RYGB is marginal ulceration, which requires urgent surgery if perforated. We sought to identify characteristics associated with elective vs urgent presentation for marginal ulcer following RYGB. Retrospective data for consecutive cases with marginal ulcers that required surgical intervention from May 2016 to February 2021 were queried from our institution's bariatric database, and differences in patient characteristics and clinical course were assessed according to presentation. Forty-three patients underwent surgery for marginal ulcer during the study timeframe. Twenty-four (56%) patients presented electively and were treated with resection of the gastroenterostomy and reanastomosis; the remaining 19 (44%) presented urgently with perforation and were treated with omental patch repair. Demographics, comorbidities, and medications were similar between groups. Patients with urgent presentations were less likely to have bleeds (0% vs. 33%, P = 0.0056) and strictures (16% vs. 46%, P = 0.0368), but were more likely to require admission to the intensive care unit (32% vs. 4%, P = 0.0325) and have a longer median length of stay (2 vs. 5 days, P < 0.0001). Bariatric surgeons must properly counsel patients about the risk of marginal ulcer development to prevent dangerous perforation, intensive care unit stays, and long hospitalizations.
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Affiliation(s)
- Matthew Wynn
- Department of Surgery, Baylor Scott & White Medical Center - Temple, Temple, Texas
| | | | - David Provost
- Department of Surgery, Baylor Scott & White Medical Center - Temple, Temple, Texas
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9
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Martinino A, Bhandari M, Abouelazayem M, Abdellatif A, Koshy RM, Mahawar K. Perforated Marginal Ulcer After Gastric Bypass for Obesity: A Systematic Review. Surg Obes Relat Dis 2022; 18:1168-1175. [PMID: 35810084 DOI: 10.1016/j.soard.2022.05.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/11/2022] [Accepted: 05/22/2022] [Indexed: 10/18/2022]
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10
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Kingma JS, Burgers DMT, Monpellier VM, Wiezer MJ, Blussé van Oud-Alblas HJ, Vaughns JD, Sherwin CMT, Knibbe CAJ. Oral drug dosing following bariatric surgery: General concepts and specific dosing advice. Br J Clin Pharmacol 2021; 87:4560-4576. [PMID: 33990981 PMCID: PMC9291886 DOI: 10.1111/bcp.14913] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022] Open
Abstract
Bariatric or weight‐loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended‐release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advice for oral drug therapy after bariatric surgery, implying that a risk assessment on a case‐by‐case basis is required for each drug.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Valerie M Monpellier
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Huis ter Heide, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Janelle D Vaughns
- Department of Anesthesia and Pain Medicine, Children's National Health System, Washington, DC, USA.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Division of Systems Biomedicine & Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
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11
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Garcia DPC, Dos Reis CF, de Figueiredo LO, Mota GVDM, Guimarães LQ, Santos FADV, Alberti LR, Furtado TDA. Perforated gastric ulcer post mini gastric bypass treated by laparoscopy: A case report. Ann Med Surg (Lond) 2019; 49:24-27. [PMID: 31871679 PMCID: PMC6909191 DOI: 10.1016/j.amsu.2019.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Among the many techniques available for bariatric surgery, the Mini Gastric Bypass is a safe, technically simple and effective option. However, it may present with postoperative complications, being the perforated gastric ulcer one of the most relevant ones. Presentation of case A female patient of 41 years of age, with past medical history of a laparoscopic MGB performed 2 year before, presented with 12 hours of sharp and abruptly initiated abdominal pain, with diffuse presentation with suspected perforated acute abdomen after initial medical assessment and examination. Imaging propaedeutic was performed and confirmed a small pneumoperitoneum the patient was submitted to a laparoscopy with closure of the leak and omental patch (Graham's patch) after a thorough abdominal irrigation with saline solution. The patient was discharged from the hospital on the fourth day after surgery. Discussion One of the most common complications after and MGB surgery is the occurrence of gastric ulcers and main manifestation of the anastomotic marginal ulcers (MU) is the perforation. The treatment of the perforated peptic ulcer can be performed via laparoscopic or laparotomic approach. The main objective, regardless of the method used to access the abdominal cavity, is to identify and close the perforation. Conclusion The perforated gastric ulcer is a complication of the mini bariatric bypasses, and the laparoscopic treatment of the perforation associated with thorough irrigation for of the abdominal cavity and omentoplasty present good results for management of this complication.
Perforated acute abdomen in 47 year old female post Mini Gastric Bypass (MGB). Gastric ulcer is a possible complication of MGB. Main manifestation of the anastomotic marginal ulcer is the perforation. Laparoscopic treatment with irrigation abdominal and omentoplasty has good outcomes.
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Affiliation(s)
- Diego Paim Carvalho Garcia
- Department of Surgery, Hospital Felício Rocho, Av. Do Contorno, 9530 - Barro Preto, Belo Horizonte, MG, 30110-934, Brazil
| | - Cyntia Ferreira Dos Reis
- Hospital Felício Rocho, Av. Do Contorno, 9530 - Barro Preto, Belo Horizonte, MG, 30110-934, Brazil
| | - Luiza Ohasi de Figueiredo
- Hospital Alberto Cavalcanti, R. Camilo de Brito, 636 - Padre Eustáquio, Belo Horizonte, MG, 30730-540, Brazil
| | | | | | | | - Luiz Ronaldo Alberti
- Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, Programa de Pós-Graduação Em Clínica Médica/Biomedicina, Avenida Francisco Sales, 1.111 9 Andar, Ala D - Santa Efigênia, Belo Horizonte, MG, 30140040, Brazil
| | - Thiago de Almeida Furtado
- Department of Surgery, Hospital Felício Rocho, Av. Do Contorno, 9530 - Barro Preto, Belo Horizonte, MG, 30110-934, Brazil
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12
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Affiliation(s)
| | - John D Scott
- 905 Verdae Boulevard, Suite 202, Greenville, SC 29607, USA
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13
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Pyke O, Yang J, Cohn T, Yin D, Docimo S, Talamini MA, Bates AT, Pryor A, Spaniolas K. Marginal ulcer continues to be a major source of morbidity over time following gastric bypass. Surg Endosc 2018; 33:3451-3456. [DOI: 10.1007/s00464-018-06618-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 12/04/2018] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Type 2 diabetes mellitus (T2DM) is increasing in prevalence and associated with numerous metabolic complications leading to increased mortality and costs. Metabolic surgery, or surgery to treat T2DM and obesity, is effective at achieving remission from T2DM. This review discusses the most commonly used surgical options including the adjustable gastric band, the Roux-en-Y gastric bypass, the sleeve gastrectomy, and the biliopancreatic diversion with duodenal switch and their ability to treat and prevent T2DM. RECENT FINDINGS There is an increasing body of literature that justifies the inclusion of metabolic surgery into the treatment algorithm for patients with obesity and T2DM. Metabolic procedures should be performed at centers that offer comprehensive treatment of metabolic disorders and have expertise in gastrointestinal surgery. The incremental improvement in the quality and safety of metabolic surgery has significantly reduced the risk of serious post-operative complications. Metabolic surgery is a safe and effective treatment option for obese patients with T2DM.
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Affiliation(s)
- Eric Rachlin
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM 390, Houston, TX, 77030, USA
| | - Carlos Galvani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM 390, Houston, TX, 77030, USA.
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15
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Managing a Positive Air-Leak Test During a Gastrojejunostomy Revision. Obes Surg 2018; 28:2983-2984. [PMID: 29915974 DOI: 10.1007/s11695-018-3338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Gastrojejunostomy revision after gastric bypass surgery is a challenging procedure that requires advanced skills. The air-leak test was performed to identify gastrojejunostomy leaks. Omental patch seal technique is a well-known treatment of perforated gastrojejunostomy ulcers (Surg Obes Relat Dis 4:423-8, 2012; Surg Endosc 2:384-9, 2013; Surg Endosc 11:2110, 2007). METHODS We present a case of a 40-year-old female, who underwent laparoscopic gastric bypass 6 years prior and subsequently developed marginal ulcer, resulting in chronic gastrojejunostomy stricture. She underwent multiple endoscopic dilations until it became refractory. She was taken for a gastrojejunostomy revision. After dissection of dense adhesion, the gastric pouch was identified. The Roux limb was identified as retrocolic and retrogastric. The pouch was divided just below the left gastric pedicle. Endoscope air insufflation was showed no leak of the new pouch. The Roux limb was freed and gastrojejunal anastomosis was performed with a posterior lair, linear stapler, and two layers of running 2-0 absorbable sutures for common enterotomy. The leak test demonstrated air bubbles which were at the anastomosis lateral aspect. A 2-0 non-absorbable suture was placed repeatedly but the leak remained positive. Fibrin glue was placed over the gastrojejunostomy. A tongue of omentum was pulled posteriorly to the pouch and sewed to itself to encircle the gastrojejunostomy. The leak test was not repeated since it would not have changed our management at this point. A remnant gastrostomy tube was placed. Two suction drains were placed. Upper endoscopy, at the end of the case, demonstrated a patulous gastrojejunostomy. RESULTS The patient's post-operative course was uneventful. Enteric feeding was initiated via the remnant gastrostomy. Upper GI fluoroscopy was performed on POD 5 and was negative for leak or stricture. She was discharged on POD 7. At 6-month follow-up, she was doing excellent, maintaining her weight without symptoms. CONCLUSIONS Gastrojejunostomy revision is a complex procedure that requires an advanced bariatric surgery skills and experience. Omental patch can be used in cases where friable tissue anastomosis leaks as a sealant along with a protective feeding gastrostomy.
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16
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Silecchia G, Iossa A. Complications of staple line and anastomoses following laparoscopic bariatric surgery. Ann Gastroenterol 2017; 31:56-64. [PMID: 29333067 PMCID: PMC5759613 DOI: 10.20524/aog.2017.0201] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/08/2017] [Indexed: 12/12/2022] Open
Abstract
With over 600 million people being obese, and given the scientific demonstration of the advantages of surgical treatment, bariatric surgery is on the rise. The promising long-term results in terms of weight loss, and particularly in relation to comorbidities and the control/cure rate, mean that the number of procedures performed in all countries remains high. However, the risk of potentially complex or fatal complications, though small, is present and is related to the procedures per se. This review is a guide for bariatric and/or general surgeons, offering a complete overview of the pathogenesis of anastomosis and staple line following the most common laparoscopic bariatric procedures: sleeve gastrectomy, gastric bypass, and mini-gastric bypass. The review is divided according to the procedure and the complications (leak, bleeding and stenosis), and evaluates all the factors that can potentially improve or worsen the complication rate, representing a “unicum” in the present literature on bariatric surgery.
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Affiliation(s)
- Gianfranco Silecchia
- Department of Medical-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Centre of Excellence, University of Rome "La Sapienza", Rome, Italy
| | - Angelo Iossa
- Department of Medical-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Centre of Excellence, University of Rome "La Sapienza", Rome, Italy
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17
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Natarajan SK, Chua D, Anbalakan K, Shelat VG. Marginal ulcer perforation: a single center experience. Eur J Trauma Emerg Surg 2017; 43:717-722. [PMID: 27619359 DOI: 10.1007/s00068-016-0723-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/06/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE Marginal ulcer (MU) is defined as ulcer on the jejunal side of the gastrojejunostomy (GJ) anastomosis. Most MUs are managed medically but those with complications like bleeding or perforation require intervention. It is recommended that GJ anastomosis be revised in patients with MU perforation (MUP). The aim of this case series is to study the clinical presentation and management of MUP. METHODS Three hundred and thirty-two patients who underwent emergency surgery for perforated peptic ulcer at a single center were studied over a period of 5 years. RESULTS Nine patients (2.7 %) presented with MUP. GJ was previously done for either complicated peptic ulcer (n = 4) or for suspected gastric malignancy (n = 5). Two patients had previously completed H. pylori therapy. None of the patients presented with septic shock. MU was on the jejunal side of GJ in all patients. The median MUP size was 10 mm. Four patients (44.4 %) had omental patch repair, three (33.3 %) had primary closure, and one each had revision of GJ and jejunal serosal patch repair. There were no leaks, intra-abdominal abscess or reoperation and no malignancies. CONCLUSION MUP patients do not present with septic shock. Omental patch repair or primary closure is sufficient enough. Revision of Billroth-II-GJ into Roux-en-Y-GJ is not mandatory.
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Affiliation(s)
- S K Natarajan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
- , 481 Yio Chu Kang Road, #03-01, Castle Green, Singapore, 787056, Singapore.
| | - D Chua
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - K Anbalakan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - V G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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18
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The natural history of perforated marginal ulcers after gastric bypass surgery. Surg Endosc 2017; 32:1215-1222. [DOI: 10.1007/s00464-017-5794-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/28/2017] [Indexed: 01/19/2023]
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19
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Chung KT, Shelat VG. Perforated peptic ulcer - an update. World J Gastrointest Surg 2017; 9:1-12. [PMID: 28138363 PMCID: PMC5237817 DOI: 10.4240/wjgs.v9.i1.1] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 11/04/2016] [Accepted: 11/27/2016] [Indexed: 02/06/2023] Open
Abstract
Peptic ulcer disease (PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer (PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirty-day mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.
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20
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The influence of prophylactic proton pump inhibitor treatment on the development of symptomatic marginal ulceration in Roux-en-Y gastric bypass patients: a historic cohort study. Surg Obes Relat Dis 2016; 12:246-52. [DOI: 10.1016/j.soard.2015.04.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 12/25/2022]
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21
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Essential bariatric emergencies for the acute care surgeon. Eur J Trauma Emerg Surg 2015; 42:571-584. [PMID: 26669688 DOI: 10.1007/s00068-015-0621-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/07/2015] [Indexed: 12/19/2022]
Abstract
Bariatric surgery is the most effective treatment for morbid obesity. Due to the high volume of weight loss procedures worldwide, the general surgeon will undoubtedly encounter bariatric patients in his or her practice. Liberal use of CT scans, upper endoscopy and barium swallow in this patient population is recommended. Some bariatric complications, such as marginal ulceration and dyspepsia, can be effectively treated non-operatively (e.g., proton pump inhibitors, dietary modification). Failure of conservative management is usually an indication for referral to a bariatric surgery specialist for operative re-intervention. More serious complications, such as perforated marginal ulcer, leak, or bowel obstruction, may require immediate surgical intervention. A high index of suspicion must be maintained for these complications despite "negative" radiographic studies, and diagnostic laparoscopy performed when symptoms fail to improve. Laparoscopic-assisted gastric band complications are usually approached with band deflation and referral to a bariatric surgeon. However, if acute slippage that results in gastric strangulation is suspected, the band should be removed immediately. This manuscript provides a high-level overview of all essential bariatric complications that may be encountered by the acute care surgeon.
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22
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Abstract
Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen M Harrison
- MRC Centre for Inflammation Research, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Morten H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Michael Ohene-Yeboah
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jon Arne Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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An evidence-based algorithm for the management of marginal ulcers following Roux-en-Y gastric bypass. Obes Surg 2015; 24:1520-7. [PMID: 24851857 DOI: 10.1007/s11695-014-1293-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
As the demand for obesity surgery grows, Roux-en-Y gastric bypass remains the most commonly performed procedure associated with low complication rates and good long-term co-morbidity resolution and weight loss. Marginal ulcers remain a cause of significant morbidity in medium and long term and are reported in every large series of this operation. Marginal ulceration is a complex problem with unclear aetiology and lack of clear consensus on its prevention and management. A clearer understanding of the available evidence regarding the prevention and treatment of marginal ulcers is needed to improve patient care. We propose an algorithm for management of patients with marginal ulcers based on the best available evidence in the literature.
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Sola R, Avery MJ, Fischer PE, Christmas AB, Green JM, Heniford BT, Sing RF. Bariatric Complications for the Acute Care Surgeon: Perforated Marginal Ulcer after a Roux-en-Y Gastric Bypass. Am Surg 2015. [DOI: 10.1177/000313481508100701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Richard Sola
- Carolinas Medical Center Charlotte, North Carolina
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25
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Chand B, Prathanvanich P. Critical Care Management of Bariatric Surgery Complications. J Intensive Care Med 2015; 31:511-28. [PMID: 26115959 DOI: 10.1177/0885066615593067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 06/01/2015] [Indexed: 12/23/2022]
Abstract
Obesity remains a major medical disease that often requires surgical intervention in morbidly obese patients. Surgical procedures have evolved and are performed routinely in most major medical centers. Outcomes are often dependent on patient characteristics, type of procedure, and preoperative planning. Risk stratification often depends on screening and optimizing known comorbidities often encountered in this patient population. A thorough understanding of the physiologic changes seen in obese patient and the commonly performed operations will allow the physician to perform optimal treatment strategies.
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Affiliation(s)
- Bipan Chand
- Department of Surgery, Loyola University, Maywood, IL, USA
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Diagnosis and Management of Perforated Duodenal Ulcers following Roux-En-Y Gastric Bypass: A Report of Two Cases and a Review of the Literature. Case Rep Surg 2015; 2015:353468. [PMID: 25949843 PMCID: PMC4408622 DOI: 10.1155/2015/353468] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 03/29/2015] [Indexed: 12/14/2022] Open
Abstract
Perforated duodenal ulcers are rare complications seen after roux-en-Y gastric bypass (RYGP). They often present as a diagnostic dilemma as they rarely present with pneumoperitoneum on radiologic evaluation. There is no consensus as to the pathophysiology of these ulcers; however expeditious treatment is necessary. We present two patients with perforated duodenal ulcers and a distant history of RYGP who were successfully treated. Their individual surgical management is discussed as well as a literature review. We conclude that, in patients who present with acute abdominal pain and a history of RYGB, perforated ulcer needs to be very high in the differential diagnosis even in the absence of pneumoperitoneum. In these patients an early surgical exploration is paramount to help diagnose and treat these patients.
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PALERMO M, ACQUAFRESCA PA, ROGULA T, DUZA GE, SERRA E. Late surgical complications after gastric by-pass: a literature review. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2015; 28:139-43. [PMID: 26176254 PMCID: PMC4737339 DOI: 10.1590/s0102-67202015000200014] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 11/27/2014] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Gastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones. METHOD Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS There were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula. CONCLUSION Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.
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Affiliation(s)
- Mariano PALERMO
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
| | - Pablo A. ACQUAFRESCA
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
| | - Tomasz ROGULA
- Cleveland Clinic Foundation, Bariatric and Metabolic Institute,
Cleveland, OH, USA
| | - Guillermo E. DUZA
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
| | - Edgardo SERRA
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
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Al Hadad M, Dehni N, Elamin D, Ibrahim M, Ghabra S, Nimeri A. Intraoperative Endoscopy Decreases Postoperative Complications in Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2015; 25:1711-5. [DOI: 10.1007/s11695-015-1604-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Fringeli Y, Worreth M, Langer I. Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-en-Y Gastric Bypass. J Obes 2015; 2015:698425. [PMID: 26557387 PMCID: PMC4628657 DOI: 10.1155/2015/698425] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/30/2015] [Accepted: 10/07/2015] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management. METHODS Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation. RESULTS Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24-62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision. CONCLUSION Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.
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Affiliation(s)
- Yannick Fringeli
- Department of Surgery, Hospital of Jura, Faubourg des Capucins 30, 2800 Delémont, Switzerland
- *Yannick Fringeli:
| | - Marc Worreth
- Department of Surgery, Hospital of Jura, Faubourg des Capucins 30, 2800 Delémont, Switzerland
| | - Igor Langer
- Department of Surgery, Hospital of Jura, Faubourg des Capucins 30, 2800 Delémont, Switzerland
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Chau E, Youn H, Ren-Fielding CJ, Fielding GA, Schwack BF, Kurian MS. Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2014; 11:1071-5. [PMID: 25868835 DOI: 10.1016/j.soard.2014.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/09/2014] [Accepted: 12/12/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Marginal ulcers (MUs) are potentially complex complications after Roux-en-Y gastric bypass. Although most resolve with medical management, some require surgical intervention. Many surgical options exist, but there is no standardized approach, and few reports of outcomes have been documented in the literature. The objective of this study was to determine the outcomes of surgical management of marginal ulcers. METHODS Data from all patients who underwent surgical intervention between 2004 and 2012 for treatment of MU after previous Roux-en-Y gastric bypass were reviewed. RESULTS Twelve patients with MUs underwent reoperation. Nine patients had associated gastrogastric fistulae (75%). The median time to reoperation was 43 months. Ten patients underwent subtotal gastrectomy, of which 9 had a revision of the gastrojejunal anastomosis and 1 did not. One underwent total gastrectomy with esophagojejunal anastomosis for ulcer after previous revisional partial gastrectomy, and 1 patient underwent video-assisted thoracoscopic truncal vagotomy for persistent ulcer-related bleeding in the early postoperative period. Three patients (25%) experienced postoperative complications associated with revisional surgery requiring reoperation. At median follow-up time of 35 months, 7 patients (58%) had chronic abdominal pain, and 4 patients (33%) had intermittent diarrhea. Three patients (25%) were lost to recent follow-up. None had recurrence of MU. CONCLUSION Patients can undergo one of several available surgical interventions, including laparoscopic subtotal gastrectomy with gastrojejunostomy revision. Though this appears to offer definitive treatment of MU, its benefits must be weighed against the increased risk of significant postoperative complications and chronic symptoms related to revisional surgery.
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Affiliation(s)
- Edward Chau
- Department of Surgery, NYU School of Medicine, New York, New York.
| | - Heekoung Youn
- Department of Surgery, NYU School of Medicine, New York, New York
| | | | | | | | - Marina S Kurian
- Department of Surgery, NYU School of Medicine, New York, New York
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Moon RC, Teixeira AF, Goldbach M, Jawad MA. Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center. Surg Obes Relat Dis 2014; 10:229-34. [DOI: 10.1016/j.soard.2013.10.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/16/2013] [Accepted: 10/01/2013] [Indexed: 01/28/2023]
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Acute complications after laparoscopic bariatric procedures: update for the general surgeon. Langenbecks Arch Surg 2013; 398:669-86. [DOI: 10.1007/s00423-013-1077-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 03/05/2013] [Indexed: 12/24/2022]
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