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Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration



Marginal ulceration (MU) is a common long-term complication following Roux-en-Y gastric bypass (RYGB). The causes of MU after RYGB are multifactorial and include surgical technique of constructing the gastrojejunal anastomosis (GJA). The purpose of this study is to evaluate the relationship between gastric pouch size in RYGB and MU using CT volumetrics.

Material and Methods

Patients were retrospectively identified who underwent esophagogastroduodenoscopy (EGD) following RYGB at a tertiary care teaching hospital. Measurement of gastric pouch size was performed using 3-D CT software. Standard statistical methods were used, a univariate comparison was performed between MU and non-MU patients followed by a propensity-matched comparison to control for factors known to affect MU, and a propensity-matched subgroup analysis was also performed.


In total, 122 patients met criteria, 57 of which had MU on EGD and 65 who did not. The MU group had more smokers and patients with PPI use than the non-MU group, and the mean time from operation to CT scan was 26.6 months (range: 0–108 months). The MU group had a larger gastric pouch size than the non-MU group (34.1 ± 11.8 versus 20.1 ± 6.8 cm3). When analyzed for matched patient cohorts, this difference remained for the MU group that included smokers and PPI use. When stratified for pouch size, for each 5 cm3 increase in pouch size, patients had 2.4 times odds increase of MU formation.


CT volumetric analysis demonstrated that a larger gastric pouch size was associated with MU following RYGB.

Graphical abstract

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Fig. 1


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There was no outside funding received for this study; all funding came directly from Atrium Health and the Section of Bariatric and Metabolic Surgery.

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Each of the above authors contributed substantially to the design of the work, the drafting of the manuscript, and the final approval of the manuscript.

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Correspondence to Sullivan A. Ayuso.

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Conflict of Interest

Dr. Nimeri receives honoraria for speaking from Medtronic. Dr. Gersin is a speaker for WL Gore and Medtronic, an investor in Standard Bariatrics, and a consultant for GI dynamics. Dr. Kuwada receives honoraria for speaking from Bard and WL Gore and is a consultant for Medtronic. The rest of the authors have nothing to disclose.

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Accepted for Oral Presentation at the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Annual Meeting, Miami, Florida, August, 2022

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Ayuso, S.A., Robinson, J.N., Okorji, L.M. et al. Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration. OBES SURG 32, 587–592 (2022).

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  • Roux-en-Y gastric bypass
  • Marginal ulceration
  • Gastric pouch
  • Computed tomography
  • Volumetric analysis