VATS vagotomy for persistent GJ ulcer after GBP: A single institution experience

Tiffany Tanner, MD, Lora Melman, MD, Erika Leung, John Price, MD, Brent Sorenson, MD. Saint Luke’s Hospital

INTRODUCTION: Marginal ulcer is a potentially serious complication after gastric bypass surgery, occurring in 5-7% of patients. Many reports in the literature describe revisional transabdominal gastrojejunostomy for ulcers that are refractory to medical management, and only one study to date (Hunter, et al. Am Surg 2012 Jun;78(6):663-8) describes transthoracic vagotomy as an alternative approach, claiming 80% effectiveness for treating persistent GJ ulcers. The purpose of our study was to examine the outcomes of patients at our institution diagnosed with medically refractory GJ ulceration, who subsequently underwent vagotomy via videoscopic-assisted thoracoscopic surgery (VATS) approach.

METHODS AND PROCEDURES: Four patients were identified retrospectively between two practicing bariatric surgeons; all who underwent laparoscopic gastric bypass at an MBSAQIP-accredited Comprehensive Center between 2008-2011. After de-identification, data was collected with regard to pre-bypass demographics (sex, age, BMI), time interval between gastric bypass and ulcer diagnosis, length of medical management trial, and documentation of healed ulcer after vagotomy. All vagotomies were performed via VATS approach.

RESULTS: Of the four patients, 3 (75%) were female and 1 (25%) was male. Average age was 59 (range 51-66 years) and average BMI was 45.3 (range 40.7-48.8). Patients developed marginal ulcer at an average of 2.7 years post-laparoscopic roux y gastric bypass (range 1.6-4 years). Medical management was prescribed for an average of 3.2 months (range 1-6 months), consisting of twice-daily proton-pump inhibitors and carafate. One patient was diagnosed with metastatic cholangiocarcinoma after vagotomy and subsequently lost to follow up. The remaining three patients had complete ulcer healing as documented by upper endoscopy at an average of 2.3 months (range 1-4 months) post-vagotomy.

CONCLUSIONS: VATS vagotomy was extremely effective in achieving complete ulcer healing of medically refractory marginal ulcers post-gastric bypass. Although our study is limited by a small number of patients, it shows a strong trend in favor of VATS vagotomy as a reasonable alternative surgical approach versus transabdominal vagotomy and revision of gastrojejunostomy.

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