Abstract
Background
Marginal ulcer formation is a known complication following RYGB. While most respond to medical therapy, many patients have recurrent or chronic MU. Although non-steroidal anti-inflammatory drug (NSAID) use, smoking and Helicobacter pylori infection are known risk factors of MU, little is known about what increases the likelihood of developing recalcitrant ulcers. The objective of this study is to identify risk factors for marginal ulcer (MU) formation, including recalcitrant ulcers requiring surgical revision, and to define the incidence and outcomes of revisional surgery.
Methods
All patients who underwent RYGB between 2011 and 2017 at a high-volume academic center were included. Patients with a postoperative diagnosis of MU were identified from the institution’s bariatric database. Patient characteristics, operative data and surgical outcomes were analyzed using data collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and the Ontario Bariatric Registry.
Results
A total of 2830 RYGB were performed during the study period. The incidence of MU was 6.9% with 1% of patients requiring revisional surgery for a recalcitrant ulcer. Patients with a history of smoking (HR 5.03), immunosuppression (HR 4.60) and preoperative NSAID use (HR 3.11) were significantly more likely to develop a MU requiring surgical revision. Patients undergoing revision reported resolution of their symptoms in only 36% of cases with 57% developing a recurrent ulcer.
Conclusion
Patients with a history of smoking and use of immunosuppressive medication were at significantly higher risk of developing MU that failed medical therapy. Additional evidence is needed to inform perioperative management of bariatric patients.
Similar content being viewed by others
References
English WJ, Demaria EJ, Brethauer SA, Mattar SG, Rosenthal RJ, Morton JM (2018) American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States In 2016. Surg Obes Relat Dis 14:259–263
Javanainen M, Penttila A, Mustonen H, Juuti A, Scheinin T, Leivonen M (2018) A retrospective 2-year follow-up of late complications treated surgically and endoscopically after laparoscopic Roux-En-Y Gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) for morbid obesity. Obes Surg 28:1055–1062
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 24:299–309
Steinemann DC, Bueter M, Schiesser M, Amygdalos I, Clavien PA, Nocito A (2014) Management of anastomotic ulcers after Roux-En-Y gastric bypass: results of an international survey. Obes Surg 24:741–746
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 10:229–234
Sverden E, Mattsson F, Sonden A, Leinskold T, Tao W, Lu Y, Lagergren J (2016) Risk factors for marginal ulcer after gastric bypass surgery for obesity: a population-based cohort study. Ann Surg 263:733–737
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
Coblijn UK, Lagarde SM, De Castro SM, Kuiken SD, Van Wagensveld BA (2015) Symptomatic marginal ulcer disease after Roux-En-Y gastric bypass: incidence, risk factors and management. Obes Surg 25:805–811
El-Hayek K, Timratana P, Shimizu H, Chand B (2012) Marginal ulcer after Roux-En-Y gastric bypass: what have we really learned? Surg Endosc 26:2789–2796
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
Chang PC, Huang CK, Tai CM, Huang IY, 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 13:588–593
Chau E, Youn H, Ren-Fielding CJ, Fielding GA, Schwack BF, Kurian MS (2015) Surgical management and outcomes of patients with marginal ulcer after Roux-En-Y gastric bypass. Surg Obes Relat Dis 11:1071–1075
Datta TS, Steele K, Schweitzer M (2010) Laparoscopic revision of gastrojejunostomy revision with truncal vagotomy for persistent marginal ulcer after Roux-En-Y gastric bypass. Surg Obes Relat Dis 6:561–562
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
Scheuermann TS, Richter KP, Rigotti NA, Cummins SE, Harrington KF, Sherman SE, Zhu SH, Tindle HA, Preacher KJ, Consortium of Hospitals Advancing Research on T (2017) Accuracy of self-reported smoking abstinence in clinical trials of hospital-initiated smoking interventions. Addiction 112:2227–2236
Chen KJ, Chen CH, Cheng CH, Wu MJ, Shu KH (2004) Risk factors for peptic ulcer disease in renal transplant patients–11 years of experience from a single center. Clin Nephrol 62:14–20
Kang X, Hong D, Anvari M, Tiboni M, Amin N, Gmora S (2017) Is daily low-dose aspirin safe to take following laparoscopic Roux-En-Y Gastric bypass for obesity surgery? Obes Surg 27:1261–1265
Gilmore MM, Kallies KJ, Mathiason MA, Kothari SN (2013) Varying marginal ulcer rates in patients undergoing laparoscopic Roux-En-Y gastric bypass for morbid obesity versus gastroesophageal reflux disease: is the acid pocket to blame? Surg Obes Relat Dis 9:862–866
Clarke AT, Wirz AA, Manning JJ, Ballantyne SA, Alcorn DJ, Mccoll KE (2008) Severe reflux disease is associated with an enlarged unbuffered proximal gastric acid pocket. Gut 57:292–297
Kang X, Zurita-Macias L, Hong D, Cadeddu M, Anvari M, Gmora S (2016) A comparison of 30-day versus 90-day proton pump inhibitor therapy in prevention of marginal ulcers after laparoscopic Roux-En-Y gastric bypass. Surg Obes Relat Dis 12:1003–1007
Coblijn UK, Lagarde SM, De Castro SM, Kuiken SD, Van Tets WF, Van Wagensveld BA (2016) 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 12:246–252
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 11:33
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
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 78:663–668
Funding
This study received no outside funding.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Dr. Di Palma reports grants from Medtronic outside the submitted work. Dr. Okrainec reports personal fees from Medtronic, personal fees from Ethicon, personal fees from Merck, outside the submitted work. Drs. Liu, Maeda, Anvari, and Jackson have no conflicts of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Di Palma, A., Liu, B., Maeda, A. et al. Marginal ulceration following Roux-en-Y gastric bypass: risk factors for ulcer development, recurrence and need for revisional surgery. Surg Endosc 35, 2347–2353 (2021). https://doi.org/10.1007/s00464-020-07650-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-020-07650-0