Skip to main content
SpringerLink
Log in

Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Marginal ulceration after Roux-en-Y gastric bypass (RYGB) is diagnosed in 1% to 16% of patients. The factors predisposing patients to marginal ulceration are still unclear.

Methods

A total of 260 patients who underwent laparoscopic RYGB were retrospectively reviewed. Data regarding demographics, comorbidities, body mass index (BMI), Helicobacter pylori infection, gastrojejunal (GJ) anastomotic leaks, postoperative bleeding, operative time, type of suture material, and marginal ulcer formation were collected. Fisher’s exact test was used for statistical analysis of discrete variables, and Student’s t-test was used for continuous variables. Statistical significance was set at an alpha of 0.05.

Results

The overall marginal ulceration rate was 7%. Demographic data (age, gender distribution, BMI) did not differ significantly between patients who experienced marginal ulceration and those who did not (p > 0.05). Similarly, technical factors (choice of permanent or absorbable suture for the GJ anastomosis, attending as primary surgeon, robotic GJ, operative time, postoperative hematocrit drop) were not statistically different between the two groups (p > 0.05). Finally, the prevalence of comorbidities (diabetes, hypertension, obstructive sleep apnea, musculoskeletal complaints, dyslipidemia, gastroesophageal reflux disease [GERD] and peptic ulcer disease [PUD]) did not differ significantly between the two groups (p > 0.05). However, preoperative H. pylori infection, although adequately treated, was twice as common among the patients who had marginal ulceration (32%) as among those who did not (12%) (p = 0.02). All the patients who experienced marginal ulcers had complete resolution of symptoms with proton pump inhibitors and sucralfate. No reoperations were required for marginal ulceration.

Conclusion

Helicobacter pylori may potentiate marginal ulcer formation. The authors hypothesize that H. pylori damages the mucosal barrier in a way that persists postoperatively, which may precipitate marginal ulceration even when the organism has been medically eradicated.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1.
Fig. 2.

Similar content being viewed by others

References

  1. Ali MR, Fuller WD, Choi MP, Wolfe BM (2005) Bariatric surgical outcomes. Surg Clin North Am 4: 835–852

    Article  Google Scholar 

  2. Behrns KE, Smith CD, Sarr MG (1994) Prospective evaluation of gastric acid secretion and cobalamin absorption following gastric bypass for clinically severe obesity. Dig Dis Sci 39: 315–320

    Article  PubMed  Google Scholar 

  3. Ben-Meir A, Sonpal I, Patterson L, Schreiber H, Salomone M, Sharma K, Kumar A, Marshall JB (2005) Cigarette smoking, but not NSAID or alcohol use or comorbidities, is associated with anastomotic ulcers in Roux-en-Y gastric bypass (RYGB) patients. Surg Obes Relat Dis 1: 263

    Article  Google Scholar 

  4. Capella JF, Capella RF (1996) Staple disruption and marginal ulceration in gastric bypass procedures for weight reduction. Obes Surg 6: 44–49

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  6. Capella JF, Capella RF (2002) An assessment of vertical banded gastroplasty–Roux-en-Y gastric bypass for the treatment of morbid obesity. Am J Surg 183: 117–123

    Article  PubMed  Google Scholar 

  7. Cleator IGM (1996) Ulcerogenesis following gastric procedures for obesity. Obes Surg 6: 260–261

    Article  PubMed  Google Scholar 

  8. Cucchi SG, Pories WJ, MacDonald EK (1995) Gastrogastric fistulas: a complication of divided gastric bypass surgery. Ann Surg 221: 387–391

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  10. Fobi MAL (1992) Marginal ulcer after gastric bypass. In: Mason EE (ed) Surgical treatment of morbid obesity. problems in general surgery, vol 9, no 2, JB Lippincott, Philadelphia pp 345–352

    Google Scholar 

  11. Fobi MAL (1993) Operations that are questionable for control of obesity. Obes Surg 3: 197–200

    Article  PubMed  Google Scholar 

  12. Fobi MAL, Lee H, Igew D (2001) Prospective comparative evaluation of stapled versus transected Silastic ring gastric bypass: six-year follow-up. Obes Surg 1: 18–24

    Article  Google Scholar 

  13. Gisbert JP, Blanco M, Pajares JM (2000) Effect of Helicobacter pylori eradication on histological lesions of gastric mucosa: an 18-month follow-up study. Rev Clin Esp 9: 480–484

    Google Scholar 

  14. Griffen WO (1997) Stomal ulcer after gastric restrictive operations. J Am Coll Surg 185: 87–88

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

    Article  PubMed  Google Scholar 

  17. 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 6: 509–513

    Article  Google Scholar 

  18. Jordan JH, Hocking MP, Rout WR, Woodward ER (1991) Marginal ulcer following gastric bypass for morbid obesity. Am Surg 57: 286–288

    PubMed  Google Scholar 

  19. Kral JG (1985) Morbid obesity and related health risks. Ann Intern Med 103: 1043–1047

    PubMed  Google Scholar 

  20. Kyzekova J, Mour J (1999) The effect of eradication therapy on histological changes in the gastric mucosa in patients with nonulcer dyspepsia and Helicobacter pylori infection: prospective randomized intervention study. Hepatogastroenterology 46: 2048–2056

    PubMed  Google Scholar 

  21. MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP (1997) Stomal ulcer after gastric bypass. J Am Coll Surg 185: 1–7

    Article  PubMed  Google Scholar 

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

    PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  24. Mason EE, Munns JR, Kealey GP (1976) Effect of gastric bypass on gastric secretion. Am J Surg 131: 162–168

    Article  PubMed  Google Scholar 

  25. National Institutes of Health (1991) Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 115: 956–961

    Google Scholar 

  26. 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 

  27. Printen KJ, Scott D, Mason EE (1980) Stomal ulcers after gastric bypass. Arch Surg 115: 525–527

    PubMed  Google Scholar 

  28. Rolls BJ (2003) The supersizing of America portion size and the obesity epidemic. Nutr Today 38: 42–53

    Article  PubMed  Google Scholar 

  29. Sacks BC, Qureshi FG, Eid GM, Collins JL, Barinas-Mitchell EJ, Schauer PR, Ramanathan RC (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 

  30. Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, Wolfe L (1992) Stomal complications of gastric bypass: incidence and outcome of therapy. Am J Gastroenterol 87: 1165–1169

    PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  32. Schauer PR, Ikramuddin S (2001) Laparoscopic surgery for morbid obesity. Surg Clin North Am 81: 1145–1179

    Article  PubMed  Google Scholar 

  33. Schirmer B, Erenoglu C, Miller A (2002) Flexible endoscopy in the management of patients undergoing Roux-en-Y gastric bypass. Obes Surg 12: 634–638

    Article  PubMed  Google Scholar 

  34. Schreiber H, Ben-Meir A, Sonpal I, Patterson L, Salomone M, Marshall JB (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

    Article  Google Scholar 

  35. Smith DC, Herkes SB, Behrns KE (1993) Gastic acid secretion and vitamin B12 absorption after vertical Roux-en-y gastric bypass for morbid obesity. Ann Surg 218: 91–96

    Article  PubMed  Google Scholar 

  36. Suerbaum S, Michetti P (2002) Helicobacter pylori infection. N Engl J Med 347: 1175–1186

    Article  PubMed  Google Scholar 

  37. Sugerman HJ, Kellum JM, Engle KM (1992) Gastric bypass for treating severe obesity. Am J Clin Nutr 55: 560–566

    Google Scholar 

  38. Wyatt HR (2003) The prevalence of obesity. Prim Care 30: 267–279

    PubMed  Google Scholar 

  39. Zimmermann-Belsing T, Feldt-Rasmussen U (2004) Obesity, the new worldwide epidemic threat to general health and our complete lack of effective treatment. Endocrinology 145: 1501–1502

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank Mr. William Smith for his assistance in accumulating data and Mrs. Marie Carvidi for her editorial assistance. This research was supported by a research grant from Stryker Endoscopy.

Author information

Authors and Affiliations

  1. Department of Surgery, University of California, Davis, 2221 Stockton Boulevard, Sacramento, CA, 95817, USA

    J. J. Rasmussen, W. Fuller & M. R. Ali

Authors
  1. J. J. Rasmussen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. W. Fuller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. R. Ali
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. R. Ali.

Additional information

Submitted for oral/poster presentation at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), April 2007

Rights and permissions

Reprints and permissions

About this article

Cite this article

Rasmussen, J.J., Fuller, W. & Ali, M.R. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc 21, 1090–1094 (2007). https://doi.org/10.1007/s00464-007-9285-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-007-9285-x

Keywords

Search

Navigation