Laparoscopic Repair of Perforated Marginal Ulcers Can Be Done With Superior Outcomes Compared With Open Repair

Girish Luthra, MD, Vladan N Obradovic, MD, Aamir Akmal, MD, Eliah M Malka, Corrine Blumling, MD, Lindsey Stratchko, MSIII, Mathew E Plank, PAC, Andrea L Plank, Nicole Woll, PhD, Jon D Gabrielsen, MD FACS, Chad Lee, Anthony T Petrick, MD FACS. Geisinger Medical Center, Danville, Pennsylvania


Introduction: Perforated marginal ulcers represent a rare, but serious complication after RYGB almost invariably requiring operative management. We hypothesize that laparoscopic repair (LR) of perforated marginal ulcers after RYGB is feasible and can be done in experienced centers  with lower morbidity when compared to open repair (OR).
Methods: A review of the institutional database of patients with a previous RYGB for the treatment of morbid obesity was carried out to identify those diagnosed with perforated marginal ulcers between March 2001 and July 2011. 24 records were identified and retrospectively reviewed. Of these, 19 patients had undergone LR and 5 patients OR. These groups were also analyzed with respect to their clinical presentation, age and BMI at presentation with the ulcer, presence of peritoneal contamination, and mean follow up. The primary outcome measure was the incidence of post-operative complications in these two groups with secondary outcome measures including OR times, EBL, LOS, and ICU stay. Statistical analysis was performed using Fisher’s exact and unpaired t tests.
Results: The average age of the patients was 46.9 years in the laparoscopic and 54.0 years in the open group, though this did not reach statistical significance. The average BMI at presentation was significantly higher in the open group (48.1 vs 29.6; p=0.024). Of the 19 patients with LR, 10 presented with an acute free perforation. The remaining 9 patients presented with intractable symptoms (pain, nausea, vomiting, poor oral intake, weight loss) or bleeding and were found to have a chronic, walled-off perforation at surgery. Of the 5 patients with OR, 1 had a free perforation and 4 presented with intractable symptoms. 9 patients had generalized peritoneal contamination in the LR group, 1 had localized contamination and 9 had completely contained perforations. In the open group, 1 had generalized contamination whilst the other 4 had completely contained perforations. Our mean follow up in the LR group was 18 months and in the OR group 35 months.
There was a trend toward a higher complication rate in the OR group (60% vs 32%). No statistically significant difference in operative time was noted between groups (162 min. LR, 212 min. OR); however, blood loss (46.7 ml vs 166 ml; p= .004), length of stay (3 days vs 12.2 days; p= 0.004), and percentage of patients requiring ICU stays (11% vs 60%; p=0.04) were significantly lower in patients undergoing LR.
Conclusions: Laparoscopic repair of a perforated marginal ulcer is feasible and compared favorably to open repair in our series. LR was associated with lower blood loss, shorter length of stay, and fewer patients requiring ICU admission compared to open repair. Although the groups are small, the laparoscopic approach to perforated marginal ulcers seems preferrable when undertaken by surgeons experienced in revisional laparoscopic bariatric surgery.

Session Number: Poster – Poster Presentations
Program Number: P479
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