Omental Patch Repair Effectively Treats Perforated Marginal Ulcers Following Roux-en-Y Gastric Bypass

Mark R Wendling, MD, John G Linn, MD, Kara Keplinger, MD, Vimal K Narula, MD, Jeffrey W Hazey, MD, Dean J Mikami, MD, Kyle A Perry, MD, W. Scott Melvin, MD, Bradley J Needleman, MD. Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH


INTRODUCTION: Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Marginal ulcer formation remains a significant complication with an incidence as high as 16%, and up to 1% of all RYGB patients will develop free perforation of a marginal ulcer. Smoking, NSAID, and steroid use have been associated with increased risk of marginal ulcer formation. Classically, this complication has required anastomotic revision, however, this approach is associated with significant morbidity. Several small series have suggested that abdominal washout with omental patch repair may be utilized in select cases. The aim of this study was to examine the management of perforated marginal ulcers following RYGB in a large academic medical center.
METHODS: All patients undergoing operative intervention for perforated ulcers between 2003 and 2011 were reviewed. Those with a history of RYGB with perforation of a marginal ulcer at the gastrojejunostomy were included in the analysis. Data collected included operative approach, operative time, blood loss, length of hospital stay, complications, smoking history, and steroid or NSAID use. Data are presented as median (range) or mean (standard deviation). Data was analyzed using an unpaired t-test.
RESULTS: Between 2003 and 2011, 16 patients required operative intervention for a perforated marginal ulcer after RYGB, 13 of whom underwent laparoscopic RYGB at our institution. Median time to presentation was 27 (2-72) months. Five patients (31%) had one risk factor and 13% (n=2) had two risk factors present. Three patients (43%) with one or more risk factors were taking PPIs at the time of perforation. Fourteen patients (88%) underwent abdominal washout with omental patch repair (5 laparoscopic, 9 open) and two required revision of their gastrojejunostomy. Compared to anastomotic revision, abdominal washout with omental patch repair was associated with shorter operative times (93±54 min vs 138±2 min, p=0.0041), decreased blood loss (77±76 mL vs 250±71 mL, p=0.0663) and reduced length of stay (6.0±1.6 days vs 11±5.7 days, p=0.2139). One patient in the anastomotic revision group developed a pulmonary embolism and subdiaphramatic abscess requiring CT guided drainage. There was one death following abdominal washout with omental patch repair in a patient who was critically ill prior to the perforation.
CONCLUSIONS: Perforated marginal ulcer represents a significant and not uncommon complication of RYGB. RYGB patients should be educated to reduce risk factors for perforation, as prolonged PPI therapy may not prevent this complication in the presence of even one risk factor. Laparoscopic or open abdominal washout with omental patch repair is a safe and effective treatment for this condition that is associated with decreased operative time; it may also decrease blood loss and hospital stay compared to anastomotic revision.

Session Number: SS09 – Obesity Surgery
Program Number: S055

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