Laparoscopic gastrojejunal revision with selective gastrectomy for intractable marginal ulcers following gastric bypass

Andrejs Rudovics, MD, Dennis Hong, MD, S Gmora, MD, M Anvari, MB, BS. McMaster University, St. Joseph’s Healthcare Hamilton.

Background: Marginal ulcers following gastric bypass for morbid obesity is a common complication. The incidence of marginal ulceration varies from 0.6 to 16%. Most marginal ulcers respond to conservative medical therapy. Marginal ulcers unresponsive to medical therapy require surgical intervention. There is very little data on laparoscopic revisional procedures for marginal ulcers. We present a case series of a single institution experience of roux-en-Y gastric bypass revisions for recalcitrant marginal ulcers.

Methods: A retrospective chart review was undertaken of roux-en-Y gastric bypass revisional surgeries for recalcitrant marginal ulcers. 13 patients underwent revisions between March 2012 and June 2013. All cases were performed laparoscopically with no conversions to open. All cases involved resection of the gastrojejunal anastomosis with selective gastrectomy. No vagotomies were performed.

Results: 12 of the 13 patients were female (92%). Presenting symptoms included pain (12 patients), vomiting (6 patients), bleeding (2 patients) and dysphagia (1 patient). All patients except for two were American Society of Anesthesiologists (ASA) class 3. One was ASA class 2 and the other was class 3E. This was due to urgency secondary to bleeding from the ulcer. Median time to revision after the original bypass was 20 months (range 8 – 43). The median length of stay was 2 days (range 2 – 7 days). The median BMI was 32 (range 21 – 45.7). The following comorbidities were present: smoking two patients (15%), diabetes type II one patient (7.6%), hypertension two patients (15%). No patients were taking NSAIDs during their treatment for marginal ulcers. Average time in the operating room was 128.4 minutes. Median blood loss was 25cc (range 0 – 300cc). There were no leaks and no mortality. One patient had a missed enterotomy that was repaired same day. Another patient needed a postoperative transfusion. Two patients needed more revisional surgery.

Conclusion: Laparoscopic revision of the gastrojejunal anastomosis for intractable marginal ulcers is feasible and a safe option for patients with medically unresponsive marginal ulcers. As experience in laparoscopic revisional surgery increases, more data needs to be published to establish the best surgical approaches and algorithms for dealing with difficult marginal ulcers.

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