Marginal Ulcer After Roux-en-Y Gastric Bypass: What Have We Really Learned?

Kevin M El-hayek, MD, Poochong Timratana, MD, Hideharu Shimizu, MD, Bipan Chand, MD FACS. Cleveland Clinic


INTRODUCTION: The definition of marginal ulcer (MU) following Roux-en-Y gastric bypass is widely debated. A significant variation of incidence is reported with ulcers being categorized as early or late based on timing from operation. The objective of our study was to review the results of upper endoscopy in symptomatic patients. We further investigated potential etiologies including patient characteristics and operative details.

METHODS AND PROCEDURES: Patients who presented with symptoms underwent upper GI endoscopy following Roux-en-Y gastric bypass. An IRB approved database was queried over the preceding 15 months (6/01/2010-8/31/2011). Collected details included patient demographics, operative conduct, presenting symptoms, and upper endoscopy findings. Statistical analysis was performed using SPSS version 18.

RESULTS: A total of 455 upper GI endoscopies were performed on 328 symptomatic patients. MU was found in 112 patients (34%). Diagnosis of MU occurred in 59 patients (53%) within 12 months of surgery, and in 53 patients (47%) greater than 12 months after surgery. The method of construction of the gastrojejunostomy was determined in 191 patients. A circular stapled technique was used in 68 patients and a linear stapled technique was used in 123 patients, of whom 22 (32%) and 49 (40%) developed MU respectively (p=0.31). In the remaining 137 patients, whose operations were done outside our institution, the type of anastomosis was unknown. Twenty-one patients used tobacco, 92 used alcohol, and 10 used NSAIDs. The incidence of MU in these patients was 9/21 (43%), 32/92 (35%), and 6/10 (60%) respectively (p>0.05). The most common presenting symptoms included pain, dysphagia, nausea, and vomiting. MU was identified in 48/113 (43%) and 20/56 (36%) of patients presenting with pain and dysphagia respectively. Suture material or staples were identified in 40 patients; however, only 14 (35%) had MU. All patients with MU were started on acid suppression and cytoprotective therapy. Forty-seven patients with MU underwent repeat endoscopy due to persistent symptoms. Of these patients, 23 (49%) had resolution of the ulcer, 18 (38%) persisted, and 6 (12%) recurred after healing on third endoscopy. Given the poor correlation of known etiologic factors (smoking, alcohol, and NSAIDs) with healing, we began random pouch biopsy for the presence of parietal cells, regardless of endoscopic findings. Biopsy was performed in 55 patients, 28 (51%) of whom had MU. Parietal cells were identified in 11/28 (39%) with MU and 7/27 (26%) without MU (p=0.29). Using univariate and multivariate analysis among healing, non-healing, and healing with recurrence, tobacco was the solitary significant risk factor for recurrence (p=0.01). Five patients underwent revisional surgery for persistent MU, and 4/5 (80%) had recurrent MU.

CONCLUSION: Patients with pain or dysphagia after gastric bypass warrant upper endoscopy given the high yield for abnormalities. While the risk factors remain unclear, a thorough investigation including tobacco, alcohol, and NSAID usage should be determined and eliminated. The presence of multiple risk factors may pose a higher challenge in ulcer resolution, leading to increased recurrence. History of tobacco use remains the sole independent risk factor for ulcer persistence.

Session Number: SS09 – Obesity Surgery
Program Number: S050

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