Abstract
Introduction
Marginal ulcer is a common complication following Roux-en-Y gastric bypass with incidence rates between 1 and 16%. Most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. Revision of the gastrojejunal (GJ) anastomosis carries significant morbidity with complication rates ranging from 10 to 50%. Thoracoscopic truncal vagotomy (TTV) may be a safer alternative with decreased operative times. The purpose of this study is to evaluate the safety and effectiveness of TTV in comparison to GJ revision for treatment of recalcitrant marginal ulcers.
Methods
A retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from 1 September 2012 to 1 September 2017. All underwent medical therapy along with lifestyle changes prior to intervention and had preoperative EGD that demonstrated a recalcitrant marginal ulcer. Revision of the GJ anastomosis or TTV was performed. Data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate.
Results
Twenty patients were identified who underwent either GJ revision (n = 13) or TTV (n = 7). There were no 30-day mortalities in either group. Mean operative time was significantly lower in the TTV group in comparison to GJ revision (95.7 ± 16 vs. 227.5 ± 89 min, respectively, p = 0.0022). Recurrence of ulcer was not significant between groups and occurred following two GJ revisions (15%) and one TTV (14%). Complication rates were not significantly different with 62% in the GJ revision group and 57% in the TTV group. Approximately 38% (5/13) of GJ revisions and 28% (2/7) of TTV patients experienced complications with Clavien–Dindo scores > 3. There was no difference in postoperative symptoms between both groups.
Conclusions
Our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. However, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Pareek M, Schauer PR, Kaplan LM, Leiter LA, Rubino F, Bhatt DL (2018) Metabolic surgery. J Am Coll Cardiol 71(6):670–687
Kux E (1953) Combined thoracoscopic vagotomy and sympathectomy in ulcus duodeni. Dtsch Med Wochenschr 78(15):574–576
Coblijn UK, Lagarde SM, de Castro SMM, Kuiken SD, van Wagensveld BA (2015) Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management. Obes Surg 25(5):805–811
Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, Van Wagensveld BA (2014) Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg 24(2):299–309
Azagury DE, Dayyeh BKA, Greenwalt IT, Thompson CC, Thompson CC (2011) Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy 43:950–954
Stefanidis D, Malireddy K, Kuwada T, Phillips R, Zoog E, Gersin KS (2013) Revisional bariatric surgery: perioperative morbidity is determined by type of procedure. Surg Endosc Other Interv Tech 27(12):4504–4510
Patel RA, Brolin RE, Gandhi A (2009) Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 5(3):317–322
Moon RC, Teixeira AF, Goldbach M, Jawad MA (2014) Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center. Surg Obes Relat Dis 10(2):229–234
Steinemann DC, Schiesser M, Clavien PA, Nocito A (2011) Laparoscopic gastric pouch and remnant resection: a novel approach to refractory anastomotic ulcers after Roux-en-Y gastric bypass: case report. BMC Surg 11(1):33
Hunter J, Stahl RD, Kakade M, Breitman I, Grams J, Clements RH (2012) Effectiveness of thoracoscopic truncal vagotomy in the treatment of marginal ulcers after laparoscopic Roux-en-Y gastric bypass. Am Surg 78(6):663–668
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(2):135–138
Proot L, Derom F, Van Bastelaere W (1978) Transthoracic vagotomy for recurrent peptic ulcer after gastrectomy. An appraisal of fifteen years experience. Acta Chir Belg 77(5):351–354
Lo Menzo E, Stevens N, Kligman M (2011) Laparoscopic revision of gastrojejunostomy and vagotomy for intractable marginal ulcer after revised gastric bypass. Surg Obes Relat Dis 7(5):656–658
Chang PC, Huang CK, Tai CM, Huang IYW, Hsin MC, Hung CM (2017) Revision using totally hand-sewn gastrojejunostomy and truncal vagotomy for refractory marginal ulcer after laparoscopic Roux-en-y gastric bypass: a case series. Surg Obes Relat Dis 13(4):588–593
Chang P-C, Huang C-K, Rajan M, Hsin M-C (2016) Revision with totally hand-sewn gastrojejunostomy and vagotomy for refractory marginal ulcer after laparoscopic roux-en-Y gastric bypass. Obes Surg 26(5):1150
Acknowledgements
We would like to acknowledge the work of our statistician Elizabeth Dewey for her work in this manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Dr. Farah Husain, Dr. Brandon Tieu, Dr. Alicia Bonanno, and Elizabeth Dewey have no conflicts of interest or financial ties to disclose. This study is unfunded.
Rights and permissions
About this article
Cite this article
Bonanno, A., Tieu, B., Dewey, E. et al. Thoracoscopic truncal vagotomy versus surgical revision of the gastrojejunal anastomosis for recalcitrant marginal ulcers. Surg Endosc 33, 607–611 (2019). https://doi.org/10.1007/s00464-018-6386-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-018-6386-7