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Early Marginal Ulcer After Roux-en-Y Gastric Bypass: MBSAQIP Database Analysis of Trends and Predictive Factors

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Abstract

Purpose

Marginal ulcer (MU) is a known complication after Roux-en-Y gastric bypass (RYGB) that carries significant morbidity. First, we aimed to determine the trends and the rates of readmission, reintervention, and reoperation of 30-day MU. Second, we aim to determine the predictive factors associated with this complication.

Materials and Methods

Patients who had 30-day marginal ulcer (MU) after LRYGB were identified using the 2015–2021 MBSAQIP database. Those who had a 30-day complication other than MU were excluded. Bivariate and logistic regression analyses were performed.

Results

Among 213,104 patients undergoing laparoscopic RYGB, 638 (0.3%) showed 30-day MU. This group of patients required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Predictive factors for 30-day MU after RYGB were renal insufficiency, history of DVT, previous cardiac stent, African American race, chronic steroid use, COPD, therapeutic anticoagulation, anastomotic leak test, GERD, and operative time > 120 min. Additionally, patients who had 30-day MU showed significantly higher rates of overall complications such as pulmonary, cardiac and renal complications, unplanned ICU admission, blood transfusions, venous thromboembolism (VTE), and non-home discharge (p < 0.05). The MU group showed similar rates of 30-day mortality as those without this complication (0.2% vs 0.1%, p = 0.587).

Conclusions

The incidence of 30-day MU following RYGB was 0.3%. Patients with MU required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Some preoperative and intraoperative factors contributed to an increased risk of 30-day MU.

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Data Availability

The data that support the findings of this study are publicly available.

References

  1. Salame M, Jawhar N, Belluzzi A, et al. Marginal ulcers after Roux-en-Y gastric bypass: etiology, diagnosis, and management. J Clin Med. 2023;12(13). https://doi.org/10.3390/jcm12134336.

  2. Carr WR, Mahawar KK, Balupuri S, et al. An evidence-based algorithm for the management of marginal ulcers following Roux-en-Y gastric bypass. Obes Surg. 2014;24(9):1520–7.

    Article  PubMed  Google Scholar 

  3. Beran A, Shaear M, Al-Mudares S, et al. Predictors of marginal ulcer after gastric bypass: a systematic review and meta-analysis. J Gastrointest Surg. 2023;27(6):1066–77.

    Article  PubMed  Google Scholar 

  4. Tian Y, Rogers AM. Marginal ulcer: diagnosis and treatment. Clinical algorithms in general surgery: a practical guide. Springer International Publishing; 2019. pp. 827–9. https://doi.org/10.1007/978-3-319-98497-1_200.

  5. El-Hayek K, Timratana P, Shimizu H, et al. Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned? Surg Endosc. 2012;26(10):2789–96.

    Article  CAS  PubMed  Google Scholar 

  6. Lee JK, Van Dam J, Morton JM, et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104(3):575–82.

    PubMed  Google Scholar 

  7. Coblijn UK, Goucham AB, Lagarde SM, et al. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg. 2014;24(2):299–309.

    Article  PubMed  Google Scholar 

  8. Verhoeff K, Mocanu V, Dang J, et al. Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients. Surg Obes Relat Dis. 2022;18(6):803–11.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Carter J, Chang J, Birriel TJ, et al. ASMBS position statement on preoperative patient optimization before metabolic and bariatric surgery. Surg Obes Relat Dis. 2021;17(12):1956–76.

    Article  PubMed  Google Scholar 

  10. Giannopoulos S, Athanasiadis DI, Clapp B, et al. Proton pump inhibitor prophylaxis after Roux-en-Y gastric bypass: a national survey of surgeon practices. Surg Obes Relat Dis. 2023;19(4):303–8.

    Article  PubMed  Google Scholar 

  11. Csendes A, Burgos AM, Altuve J, et al. 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. 2009;19(2):135–8.

    Article  PubMed  Google Scholar 

  12. Pantea M, Negovan A, Banescu C, et al. Factors associated with recurrent ulcers in patients with gastric surgery after more than 15 years: a cross-sectional single-center study. Gastroenterol Res Pract. 2018;2018:8319481.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Cheung J, Yu A, LaBossiere J, et al. Peptic ulcer bleeding outcomes adversely affected by end-stage renal disease. Gastrointest Endosc. 2010;71(1):44–9.

    Article  PubMed  Google Scholar 

  14. Rodrigo DC, Jill S, Daniel M, et al. Which factors correlate with marginal ulcer after surgery for obesity? Obes Surg. 2020;30(12):4821–7.

    Article  PubMed  Google Scholar 

  15. Sverdén E, Mattsson F, Sondén A, et al. Risk factors for marginal ulcer after gastric bypass surgery for obesity: a population-based cohort study. Ann Surg. 2016;263(4):733–7.

    Article  PubMed  Google Scholar 

  16. Conn HO, Poynard T. Corticosteroids and peptic ulcer: meta-analysis of adverse events during steroid therapy. J Intern Med. 1994;236(6):619–32.

    Article  CAS  PubMed  Google Scholar 

  17. Coblijn UK, Lagarde SM, de Castro SM, et al. Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management. Obes Surg. 2015;25(5):805–11.

    Article  PubMed  Google Scholar 

  18. Clapp B, Hahn J, Dodoo C, et al. Evaluation of the rate of marginal ulcer formation after bariatric surgery using the MBSAQIP database. Surg Endosc. 2019;33(6):1890–7.

    Article  PubMed  Google Scholar 

  19. AbiMosleh K, Belluzzi A, Salame M, et al. Long-term outcomes of bariatric surgery in patients on chronic anticoagulation. Obes Surg. 2023;33(12):4007–16.

    Article  Google Scholar 

  20. White RH, Keenan CR. Effects of race and ethnicity on the incidence of venous thromboembolism. Thromb Res. 2009;123(Suppl 4):S11–7.

    Article  CAS  PubMed  Google Scholar 

  21. Schirmer BD, Meyers WC, Hanks JB, et al. Marginal ulcer. A difficult surgical problem. Ann Surg. 1982;195(5):653–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Mason EE, Munns JR, Kealey GP, et al. Effect of gastric bypass on gastric secretion. Am J Surg. 1976;131(2):162–8.

    Article  CAS  PubMed  Google Scholar 

  23. Gilmore MM, Kallies KJ, Mathiason MA, et al. 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. 2013;9(6):862–6.

    Article  PubMed  Google Scholar 

  24. Jordan JH, Hocking MP, Rout WR, et al. Marginal ulcer following gastric bypass for morbid obesity. Am Surg. 1991;57(5):286–8.

    CAS  PubMed  Google Scholar 

  25. Fakas S, Elias M, Lim D, et al. Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review. Surg Endosc. 2021;35(12):6489–96.

    Article  PubMed  Google Scholar 

  26. Salame M, Teixeira AF, Lind R, et al. Marginal ulcer and dumping syndrome in patients after duodenal switch: a multi-centered study. J Clin Med. 2023;12(17). https://doi.org/10.3390/jcm12175600.

  27. Hurwitz N, Segal M, Marbach I, et al. Differential activation of yeast adenylyl cyclase by Ras1 and Ras2 depends on the conserved N terminus. Proc Natl Acad Sci U S A. 1995;92(24):11009–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Rasmussen JJ, Fuller W, Ali MR. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc. 2007;21(7):1090–4.

    Article  CAS  PubMed  Google Scholar 

  29. Süsstrunk J, Wartmann L, Mattiello D, et al. Incidence and prognostic factors for the development of symptomatic and asymptomatic marginal ulcers after Roux-en-Y gastric bypass procedures. Obes Surg. 2021l;31(7):3005–14.

    Article  PubMed  Google Scholar 

  30. Bjarnason I, Scarpignato C, Holmgren E, et al. Mechanisms of damage to the gastrointestinal tract from nonsteroidal anti-inflammatory drugs. Gastroenterology. 2018;154(3):500–14.

    Article  CAS  PubMed  Google Scholar 

  31. Skogar ML, Sundbom M. Nonsteroid anti-inflammatory drugs and the risk of peptic ulcers after gastric bypass and sleeve gastrectomy. Surg Obes Relat Dis. 2022;18(7):888–93.

    Article  PubMed  Google Scholar 

  32. Dittrich L, Schwenninger MV, Dittrich K, et al. Marginal ulcers after laparoscopic Roux-en-Y gastric bypass: analysis of the amount of daily and lifetime smoking on postoperative risk. Surg Obes Relat Dis. 2020;16(3):389–96.

    Article  PubMed  Google Scholar 

  33. Li LF, Chan RL, Lu L, et al. Cigarette smoking and gastrointestinal diseases: the causal relationship and underlying molecular mechanisms (review). Int J Mol Med. 2014;34(2):372–80.

    Article  CAS  PubMed  Google Scholar 

  34. Boerlage TCC, Wolvers PJD, Bruin SC, et al. Upper endoscopy after Roux-en-Y gastric bypass: diagnostic yield and factors associated with relevant findings. Surg Obes Relat Dis. 2020;16(7):868–76.

    Article  PubMed  Google Scholar 

  35. Engen PA, Green SJ, Voigt RM, et al. The gastrointestinal microbiome: alcohol effects on the composition of intestinal microbiota. Alcohol Res. 2015;37(2):223–36.

    PubMed  PubMed Central  Google Scholar 

  36. Steinemann DC, Bueter M, Schiesser M, et al. Management of anastomotic ulcers after Roux-en-Y gastric bypass: results of an international survey. Obes Surg. 2014;24(5):741–6.

    Article  PubMed  Google Scholar 

  37. Schulman AR, Chan WW, Devery A, et al. Opened proton pump inhibitor capsules reduce time to healing compared with intact capsules for marginal ulceration following Roux-en-Y gastric bypass. Clin Gastroenterol Hepatol. 2017;15(4):494-500.e1.

    Article  CAS  PubMed  Google Scholar 

  38. Kumbhari V, le Roux CW, Cohen RV. Endoscopic evaluation and management of late complications after bariatric surgery: a narrative review. Obes Surg. 2021;31(10):4624–33.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of General Surgery, Mayo Clinic, Jacksonville, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA

    Jorge Cornejo, Lorna A. Evans, Nafiye Busra Celik & Enrique F. Elli

Authors
  1. Jorge Cornejo
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  2. Lorna A. Evans
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  3. Nafiye Busra Celik
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  4. Enrique F. Elli
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Correspondence to Enrique F. Elli.

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Key Points

• The incidence of 30-day marginal ulcer (MU) after Roux-en-Y gastric bypass was 0.3%. The rates of 30-day MU have decreased from 3.48 to 2.37 per 1000 person/year from 2015 to 2021.

• Patients with 30-day MU required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively.

• Preoperative factors such as renal insufficiency, history of DVT, previous cardiac stent, African American race, chronic steroid, COPD, anticoagulation use, and GERD, and intraoperative factors such as anastomotic leak test and increased operative time were identified as predictive factors for 30-day MU.

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Cornejo, J., Evans, L.A., Celik, N.B. et al. Early Marginal Ulcer After Roux-en-Y Gastric Bypass: MBSAQIP Database Analysis of Trends and Predictive Factors. OBES SURG 34, 1536–1543 (2024). https://doi.org/10.1007/s11695-024-07179-4

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