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Physiopathology and Treatment of Anastomotic Ulcer: An Emerging Pathology?

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Endoscopic Follow-up of Digestive Anastomosis

Abstract

Anastomotic ulcer in the upper gastrointestinal tract is a relatively infrequent lesion which generally occurs in gastrojejunal anastomosis. Different alterations have been involved in its pathogenesis, which likely remains multifactorial. Several risk factors have been identified, including NSAID use and smoking habit, while postoperative proton pump inhibitor therapy exerts a protective effect. Data on the potential role of H. pylori are still controversial, and further well-designed studies are needed. Improvement of surgical technique (absorbable suture, small pouch, reinforced stapler, etc.) could reduce the incidence of marginal ulcer. Novel therapies based on perianastomotic injection with different stimulating factors showed promising results in experimental models. The marginal ulcer may remain asymptomatic or cause different symptoms requiring a prompt upper endoscopy. Prolonged proton pump inhibitor therapy seems to be the best medical approach, and the ulcer healing need to be confirmed. Indeed, some patients may experience an ulcer complication (bleeding, perforation, and stenosis) requiring either an endoscopic or a surgical approach in selected cases.

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References

  1. de Melo SW, Gupta S, Arenas J et al (2008) Single-balloon enteroscopy-guided hemostasis of an anastomotic ulcer in a patient with simultaneous enteric-drained pancreas-kidney transplant. Endoscopy 40:E164

    Article  PubMed  Google Scholar 

  2. Peter Z, Bodoky G, Szabò Z et al (2004) Ileocolic anastomotic ulcer after surgery in adulthood: case report and review of the literature. Z Gastroenterol 42:605–608

    Article  PubMed  CAS  Google Scholar 

  3. Monsanto P, Almeida N, Lérias C et al (2012) Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding? Rev Esp Enferm Dig 104:190–196

    Article  PubMed  Google Scholar 

  4. Karmali S, Stoklossa CJ, Sharma A et al (2010) Bariatric surgery. Can Fam Physician 56:873–879

    PubMed Central  PubMed  Google Scholar 

  5. Sapala JA, Wood MH, Sapala MA et al (1998) Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 8:505–516

    Article  PubMed  CAS  Google Scholar 

  6. Capella JF, Capella RF (1999) Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 9:22–27

    Article  PubMed  CAS  Google Scholar 

  7. Schauer R, Ikramuddin S, Gourash W et al (2000) Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 232:515–529

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  8. Higa KD, Boone KB, Ho T (2000) Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients – what have we learned? Obes Surg 10:509–513

    Article  PubMed  CAS  Google Scholar 

  9. Sugerman HJ, DeMaria EJ, Kellum JM et al (2004) Effects of bariatric surgery in older patients. Ann Surg 240:243–247

    Article  PubMed Central  PubMed  Google Scholar 

  10. Lujan JA, Frutos MD, Hernández Q et al (2005) Experience with the circular stapler for the gastrojejunostomy in laparoscopic gastric bypass (350 cases). Obes Surg 15:1096–1102

    Article  PubMed  Google Scholar 

  11. Sacks BC, Mattar SG, Qureshi FG et al (2006) Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2:11–16

    Article  PubMed  Google Scholar 

  12. Dallal RM, Bailey LA (2006) Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis 2:455–459

    Article  PubMed  Google Scholar 

  13. Wilson JA, Romagnuolo J, Byrne K et al (2006) Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol 101:2194–2199

    Article  PubMed  Google Scholar 

  14. Yang CS, Lee WJ, Wang HH et al (2006) The influence of Helicobacter pylori infection on the development of gastric ulcer in symptomatic patients after bariatric surgery. Obes Surg 16:735–739

    Article  PubMed  Google Scholar 

  15. Gumbs AA, Duffy AJ, Bell RL (2006) Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis 4:460–463

    Article  Google Scholar 

  16. Ramsussen 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

    Article  Google Scholar 

  17. Suggs WJ, Kouli W, Lupovic M et al (2007) Complications at gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass: comparison between 21- and 25-mm circular staplers. Surg Obes Relat Dis 3:508–514

    Article  PubMed  Google Scholar 

  18. Han SH, Gracia C, Mehran A et al (2007) Improved outcomes using a systematic and evidence-based approach to the laparascopic Roux-en-Y gastric bypass in a single academic institution. Am Surg 73:955–958

    PubMed  Google Scholar 

  19. Papasavas P, Gagné DJ, Donnelly PE et al (2008) Prevalence of Helicobacter pylori infection and value of preoperative testing and treatment in patients undergoing laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 4:383–388

    Article  PubMed  Google Scholar 

  20. Cariani S, Palandri P, Della Valle E et al (2008) Italian multicenter experience of Roux-en-Y gastric bypass on vertical banded gastroplasty: four-year results of effective and safe innovative procedure enabling traditional endoscopic and radiographic study of bypassed stomach and biliary tract. Surg Obes Relat Dis 4:16–25

    Article  PubMed  Google Scholar 

  21. Lee JK, Van Dam J, Morton JM et al (2009) Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol 104:575–582

    Article  PubMed  Google Scholar 

  22. Ruiz-de-Adana C, López-Herrero J, Hernández-Matías A et al (2008) Laparoscopic hand-sewn gastrojejunal anastomosis. Obes Surg 18:1074–1076

    Article  PubMed  Google Scholar 

  23. Vasquez JC, Wayne Overby D, Farrell TM (2009) Fewer gastrojejunostomy strictures and marginal ulcers with absorbable suture. Surg Endosc 23:2011–2015

    Article  PubMed  Google Scholar 

  24. Csendes A, Burgos AM, Altuve J et al (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 19:135–138

    Article  PubMed  Google Scholar 

  25. Ramirez MC, Rodriguez J, Varghese F et al (2010) Reinforced circular stapler in bariatric surgery. JSLS 14:358–363

    Article  PubMed Central  PubMed  Google Scholar 

  26. Garrido AB Jr, Rossi M, Lima SE Jr et al (2010) Early marginal ulcer following Roux-en-Y gastric bypass under proton pump inhibitor treatment – prospective multicentric study. Arq Gastroenterol 47:130–134

    Article  Google Scholar 

  27. Suter M, Donadini A, Calmes JM et al (2010) Improved surgical technique for laparoscopic Roux-en-Y gastric bypass reduces complications at the gastrojejunostomy. Obes Surg 20:841–845

    Article  PubMed  Google Scholar 

  28. Bendewald FP, Choi JN, Blythe LS et al (2011) Comparison of hand-sewn, linear-stapled, and circular-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg 21:1671–1675

    Article  PubMed  Google Scholar 

  29. Rawlins L, Rawlins MP, Brown CC et al (2013) Effect of Helicobacter pylori on marginal ulcer and stomal stenosis after Roux-en-Y gastric bypass. Surg Obes Relat Dis 9:760–764

    Article  PubMed  Google Scholar 

  30. Callery CD, Filiciotto S, Neil KL (2012) Collagen matrix staple line reinforcement in gastric bypass. Surg Obes Relat Dis 8:185–189

    Article  PubMed  Google Scholar 

  31. Levitzky BE, Wassef WY (2010) Endoscopic management in the bariatric surgical patient. Curr Opin Gastroenterol 26:632–639

    Article  PubMed  Google Scholar 

  32. Mayer G, Lingenfelser T, Ell TC (2004) The role of endoscopy in early postoperative haemorrhage. Best Pract Res Clin Gastroenterol 18:799–807

    Article  PubMed  Google Scholar 

  33. Vanek VW, Catania M, Triveri K et al (2006) Retrospective review of the preoperative biliary and gastrointestinal evaluation for gastric bypass surgery. Surg Obes Relat Dis 2:17–23

    Article  PubMed  Google Scholar 

  34. Kalaiselvan R, Exarchos G, Hamza N et al (2012) Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management. Surg Obes Relat Dis 8:423–428

    Article  PubMed  Google Scholar 

  35. Wendling MR, Linn JG, Keplinger KM et al (2013) Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass. Surg Endosc 27:384–389

    Article  PubMed  Google Scholar 

  36. Mason EE (1996) Ulcerogenesis in surgery for obesity. Obes Surg 6:180–181

    Article  PubMed  Google Scholar 

  37. Ramaswamy A, Lin E, Ramshaw BJ, Smith CD (2004) Early effects of Helicobacter pylori infection in patients undergoing bariatric surgery. Arch Surg 139:1094–1096

    Article  PubMed  Google Scholar 

  38. Hartin CW, ReMine DS, Lucktong TA (2009) Preoperative bariatric screening and treatment of Helicobacter pylori. Surg Endosc 23:2531–2534

    Article  PubMed  Google Scholar 

  39. Marano BJ (2005) Endoscopy after Roux-en-Y gastric bypass: a community hospital experience. Obes Surg 15:342–345

    Article  PubMed  Google Scholar 

  40. Schreiber H, Ben-Meir A, Sonpal I et al (2005) Cigarette smoking, but not the presence of H. pylori, is associated with anastomotic ulcers in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 1:257 (abstract)

    Article  Google Scholar 

  41. Zullo A, Hassan C, Campo SMA et al (2007) Bleeding peptic ulcer in the elderly risk factors and prevention strategies. Drugs Aging 24:815–828

    Article  PubMed  CAS  Google Scholar 

  42. MacLean LD, Rhode BM, MacLean AP et al (1997) Stomal ulcer after gastric bypass. J Am Coll Surg 185:1–7

    Article  PubMed  CAS  Google Scholar 

  43. Hedberg J, Hedenstrom H, Nilsson S et al (2005) Role of gastric acid in stomal ulcer after gastric bypass. Obes Surg 15:1375–1378

    Article  PubMed  Google Scholar 

  44. Pope GD, Goodney PP, Burchard KW (2002) Peptic ulcer/stricture after gastric bypass: a comparison of technique and acid suppression variables. Obes Surg 12:30–33

    Article  PubMed  Google Scholar 

  45. Steinemann DC, Schiesser M, Clavien PA et al (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

    Article  PubMed Central  PubMed  Google Scholar 

  46. Zimmermann R, Jakubietz R, Jakubietz M et al (2001) Different preparation methods to obtain platelet components as a source of growth factors for local application. Transfusion 41:1217–1224

    Article  PubMed  CAS  Google Scholar 

  47. Wallace JL, Dicay M, McKnight W et al (2006) Platelets accelerate gastric ulcer healing through presentation of vascular endothelial growth factor. Br J Pharmacol 148:274–278

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  48. Sarıbeyoglu G, Baca B, Hamzaoglu I et al (2003) Does becaplermin (Platelet-Derived Growth Factor-BB) reverse detrimental effects of ischemia on colonic anastomosis? Dis Colon Rectum 46:516–520

    Article  PubMed  Google Scholar 

  49. Stumpf M, Junge K, Rosch R et al (2009) Suture-free small bowel anastomoses using collagen fleece covered with fibrin glue in pigs. J Invest Surg 22:138–147

    Article  PubMed  Google Scholar 

  50. Dinca S, Gulcelika MA, Kurua B et al (2004) Effects of locally applied recombinant Human Granulocyte-Macrophage Colony-Stimulating factor on ischemic bowel anastomoses in rat. Eur Surg Res 36:59–63

    Article  CAS  Google Scholar 

  51. Tasdlen A, Algin C, Ates E et al (2004) Effect of leptin on healing of colonic anastomoses in rats. Hepatogastroenterology 51:994–997

    Google Scholar 

  52. Yoo HJ, Shin JH, An MS et al (2012) Adipose-tissue-derived stem cells enhance the healing of ischemic colonic anastomoses: an experimental study in rats. J Korean Soc Coloproctol 28:132–139

    Article  PubMed Central  PubMed  Google Scholar 

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Authors and Affiliations

  1. Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Via E. Morosini, 30, Rome, 00153, Italy

    Angelo Zullo & Cesare Hassan

  2. Gastroenterology Unit, “Sapienza” University of Rome – Polo Pontino, Via F. Fagiana 1668, Latina, 04100, Italy

    Lorenzo Ridola

Authors
  1. Angelo Zullo
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  2. Lorenzo Ridola
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  3. Cesare Hassan
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Correspondence to Angelo Zullo .

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Editors and Affiliations

  1. University of Naples Federico II, Napoli, Italy

    Giuseppe Galloro

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Zullo, A., Ridola, L., Hassan, C. (2014). Physiopathology and Treatment of Anastomotic Ulcer: An Emerging Pathology?. In: Galloro, G. (eds) Endoscopic Follow-up of Digestive Anastomosis. Springer, Milano. https://doi.org/10.1007/978-88-470-5370-0_11

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  • DOI: https://doi.org/10.1007/978-88-470-5370-0_11

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