Gastric Bypass is an increasingly common procedure. Associated rare complications have a related increased occurrence. Marginal ulceration at the gastrojejunal anastomosis has a reported incidence of 5 to 12%. In most instances these ulcers can be managed conservatively using acid suppression with proton pump inhibitors and sucralfate. There is a troublesome subset of this population, resistant to conservative measures. They are the patients with chronic epigastric pain and persistent marginal ulcerations. These patients find themselves at an increased risk for significant complications of bleeding and perforation at the ulcer site. It is possible that this subset likely has remnant parietal cells in the gastric pouch. If parietal cells remain innervated by vagal fibers, intuitively there will be persistently elevated levels of acid across the gastrojejunal anastomosis amendable to suppression by vagotomy. This study reviews our experience with video assisted thoracoscopy vagotomy as an option in the treatment of persistent marginal ulcers after gastric bypass.
A retrospective analysis of 11 patients was performed by means of chart review and phone interviews. All patients had Laparoscopic Roux-en-Y Gastric Bypass performed in similar fashion by the same group of surgeons after EGD evidence of marginal ulceration resistant to medical management. These patients underwent vagotomy by a single surgeon over a one-year period. Access was via four to five 5mm chest ports and involved division and clipping of both branches of the vagus nerve at the level of the distal esophagus. After chart review, patients were contacted by phone and interviewed about their current related symptoms and medications.
Eleven patients underwent VATS vagotomy for chronic marginal ulceration. The average original BMI was 52.8 (45.7-62.1). Average weight loss 146.5 lb (84-244). Average post VATS follow-up 6 mo (1-12). Average EGD performed after VATS was 4. Ulcer resolution occurred in 8 of the 11 patients. Five of 11 had gastrojejunal anastomosis revision with subsequent ulceration prior to VATS. Two patients required gastrojejunal anastomotic revision after VATS vagotomy. Eight patients had improvement in their associated pain and symptoms. There were no complications related to the VATS procedure.
VATS vagotomy is a useful tool in the treatment of the complicated post gastric bypass patient with chronic marginal ulceration. 73% of our study population had resolution of ulceration and 73% had improvement in associated symptoms. Further investigation will be helpful in delineating the details of this unique approach to a difficult condition.
Program Number: P014