Perforated Marginal Ulcers after Laparoscopic Gastric Bypass

Introduction: A perforated marginal ulcer (PMU) following laparoscopic Roux-en-y gastric bypass (LRYGB) is a potentially serious complication, but the incidence and etiology has rarely been investigated. We therefore performed a retrospective review of all patients undergoing LRYGB at our center to determine our incidence of perforated marginal ulcer and if any causative factors could be elucidated.
Method: A prospectively kept data base of all LRYGB patients at our bariatric center was retrospectively reviewed. The complete records of patients with a PMU were individually examined for accuracy and analyzed for treatment, outcome and possible underlying causes of the marginal perforation.
Results: Between 4/99 – 8/07, 1% (35 of 3430) patients undergoing laparoscopic gastric bypass at our center with a median long term follow-up of 4 years developed one or more perforated marginal ulcers 3 to 70 months (median 18 months) following laparoscopic gastric bypass. Fifteen perforations were treated laparoscopically and 20 open. The mean age 37 vs. 41 years, weight of 286 vs. 287 pounds, BMI 46 vs. 47, and gender 89% vs. 83% female of all patients with or without perforation respectively were not significantly different. Two patients with perforations (6%) were taking steroids, 10 (29%) were on N-saids at the time of perforation, 18 (51%) were actively smoking, and 6 of the smokers were also taking N-saids. Eleven (31%) of patients that perforated did not have at least one of these possible risk factors, but 4 of 11(36%) of this group had been treated post bypass for a marginal ulcer. Only 7 of 35 (20%) or 7 (0.2%) of 3430 patients perforated without any warning. There were no deaths in either group, but 3 patients re-perforated and all of these continued to smoke after their first perforation.
Conclusion: The incidence of perforation of a marginal ulcer following laparoscopic Roux-en-Y gastric bypass in this large series of patients followed over a long period was significant (>1%) and appeared to be related to smoking, N-said use or steroids in the majority of the cases. Although all LRYGB patients are at risk for perforation, only 0.2% of all patients acutely perforated without some risk factor or warning, suggesting that long term ulcer prophylaxis or treatment may be necessary to prevent this serious complication in only a select group of high risk patients.

Session: Podium Presentation

Program Number: S088