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Kachmar M, Corpodean F, Danos DM, Cook MW, Schauer PR, Albaugh VL. Early marginal ulceration prevalence following primary RYGB: a rare events model of the MBSAQIP 2015-2021. Surg Obes Relat Dis 2024; 20:916-924. [PMID: 39060190 DOI: 10.1016/j.soard.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/05/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024]
Abstract
PURPOSE Marginal ulceration (MU) following Roux-en-Y gastric bypass (RYGB) is an established complication, with early MU (within 30-days of operation) being less understood compared to its late counterpart. This study aims to identify risk factors for early MU in patients undergoing primary RYGB. METHODS Utilizing data from the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP 2015-2021), 1,346,468 records were evaluated. After exclusions for revisions, conversions, pediatric cases, nonbinary gender, missing body mass index (BMI) data, and missing operative time; 291,625 cases of primary RYGB were included for full analysis and rare events modeling of early MU. RESULTS The prevalence of early MU was .29% (n = 850). Higher rates of early MU were associated with BMI, race, history of diabetes mellitus (DM), prior thrombotic complications (deep vein thrombosis (DVT) and pulmonary embolism (PE)), prior percutaneous cardiac intervention (PTC), immunosuppressive therapy, and anticoagulation status. Additionally, procedural aspects like the nonspecialization of the surgeon and longer operative times also correlated with higher early MU rates. Rare-events regression modeling noted significant associations of early MU with younger age, diabetes requiring insulin, history of PTC, DVT, immunosuppressive therapy, and anticoagulation status. CONCLUSION Early MU remains a relatively rare complication. The lower than previously reported occurrence suggests possible improvements in both patient preparation and surgical technique. The identification of relevant risk factors enables better perioperative and intraoperative management of patients at risk of developing early MU.
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Affiliation(s)
- Michael Kachmar
- Metamor Institute, Pennington Biomedical Research Center at Louisiana State University, Baton Rouge, Louisiana; Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Florina Corpodean
- Metamor Institute, Pennington Biomedical Research Center at Louisiana State University, Baton Rouge, Louisiana; Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Denise M Danos
- Department of Behavioral & Community Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Michael W Cook
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana; University Medical Center, New Orleans, Louisiana
| | - Philip R Schauer
- Metamor Institute, Pennington Biomedical Research Center at Louisiana State University, Baton Rouge, Louisiana; Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Vance L Albaugh
- Metamor Institute, Pennington Biomedical Research Center at Louisiana State University, Baton Rouge, Louisiana; Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.
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Vij S, Too A, Tsang V, Kreutzwiser D. Analgesic medication considerations for chronic pain management post-bariatric surgery. Expert Opin Drug Metab Toxicol 2024:1-10. [PMID: 39193986 DOI: 10.1080/17425255.2024.2398631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/11/2024] [Accepted: 08/27/2024] [Indexed: 08/29/2024]
Abstract
INTRODUCTION Bariatric surgery, an option for obesity management, can significantly alter gastrointestinal structure and processes. These changes can impact the pharmacokinetics (PK) of medications, which can translate to clinical differences in efficacy and safety. Chronic pain is prevalent in obesity and often persists post-bariatric surgery. AREAS COVERED This narrative review examines the PubMed literature from 1990 to January 2024 for the impact of bariatric surgery on the management of chronic pain medications including non-opioid (acetaminophen, non-steroidal anti-inflammatory drugs, antidepressants, and cannabinoids) and opioid medications. EXPERT OPINION An individualized medication management approach is ideal for post-bariatric surgery patients, as PK parameters, type of surgery, time since surgery, and patient-specific factors make it difficult to support blanket recommendations. Close monitoring of efficacy and safety outcomes is essential in chronic pain management. While the PK of acetaminophen and opioids are impacted, the value of these medications in the setting of chronic pain is dwindling as more efficacy and safety data emerges. A life-long ban of NSAIDs due to marginal ulcer risk is not endorsed; rather, we advocate for shifting the focus to marginal ulcer prevention strategies, individualized benefit-risk analysis, and safety monitoring using surrogate markers.
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Affiliation(s)
- Sumani Vij
- Pharmacy Department, St. Joseph's Health Care London, London, Ontario, Canada
| | - Adriana Too
- Pharmacy Department, St. Joseph's Health Care London, London, Ontario, Canada
| | - Victor Tsang
- Pharmacy Department, St. Joseph's Health Care London, London, Ontario, Canada
| | - Denise Kreutzwiser
- Pharmacy Department and Pain Management Program, St. Joseph's Health Care London, London, Ontario, Canada
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Jawhar N, Abi Mosleh K, Bartosiak KZ, Hage K, Kennel KA, Mundi MS, Kendrick ML, Ghanem OM. Comprehensive outcomes after Roux-en-Y gastric bypass with a near-complete 15-year follow-up. Surgery 2024; 176:586-594. [PMID: 38769035 DOI: 10.1016/j.surg.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/23/2024] [Accepted: 02/25/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass has a well-established safety and efficacy profile in the short and mid-term. Long-term outcomes remain limited in the literature, especially for follow-up periods of >10 years. The purpose of the study is to evaluate the long-term durability and safety of laparoscopic Roux-en-Y gastric bypass over a near-complete 15-year follow-up. METHODS This is a single-center retrospective cohort study of patients who underwent primary laparoscopic Roux-en-Y gastric bypass between 2008 and 2009 with ≥14-year follow-up. Data collected and analyzed were weight loss, obesity-related medical condition resolution and recurrence, weight recurrence, complication rate, and mortality rate. RESULTS A total of 264 patients were included. Patients were predominantly female (81.8%), and the mean age and preoperative body mass index were 48.5 ± 12.2 years and 44.9 ± 7.3 kg/m2, respectively. The maximum mean percentage total weight loss achieved at 1 year was 31.5% ± 5.7% and was consistently >20% throughout follow-up. Sustained resolution of obesity-related medical conditions was achieved with a remission rate of 60.8% for type 2 diabetes mellitus, 46.7% for denoted dyslipidemia, and 40% for hypertension. Obesity-related medical condition recurrence was observed with a recurrence rate of 24.1% for type 2 diabetes mellitus, 17.9% for hypertension, and 14.8% for denoted dyslipidemia. Significant factors associated with weight loss were maximum percentage total weight loss and preoperative type 2 diabetes mellitus. Over 15 years, the weight recurrence rate was 51.1%, with predictors of higher preoperative body mass index and preoperative type 2 diabetes mellitus. CONCLUSION Laparoscopic Roux-en-Y gastric bypass provides sustainable weight loss over a 15-year period, with consistent long-term weight-loss outcomes and resolution of obesity-related medical conditions sustained for ≥10 years after surgery.
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Affiliation(s)
- Noura Jawhar
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Karl Hage
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Kurt A Kennel
- Division of Endocrinology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Manpreet S Mundi
- Division of Endocrinology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Chen S, Chiang J, Ghanem O, Ferzli G. Decision-making Considerations in Revisional Bariatric Surgery. Surg Laparosc Endosc Percutan Tech 2024; 34:400-406. [PMID: 38963277 DOI: 10.1097/sle.0000000000001296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 05/16/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries. MATERIALS AND METHODS The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG). RESULTS AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB. CONCLUSIONS As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.
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Affiliation(s)
- Sheena Chen
- Department of General Surgery, New York University Langone Health, Brooklyn, NY
| | - Jessica Chiang
- Department of General Surgery, New York University Langone Health, Brooklyn, NY
| | - Omar Ghanem
- Department of General Surgery, Mayo Clinic, Rochester, MN
| | - George Ferzli
- Department of General Surgery, New York University Langone Health, Brooklyn, NY
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Jazi AHD, Mehrnia N, Teimoury T, Shahmiri SS. Simultaneous Occurrence of Two Perforated Marginal Ulcer After Roux-en-Y Gastric Bypass Without Any Risk Factor. Obes Surg 2024; 34:3140-3141. [PMID: 38965188 DOI: 10.1007/s11695-024-07375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Amir Hossein Davarpanah Jazi
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Minimally Invasive Surgery Research Center, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nariman Mehrnia
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Taher Teimoury
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Minimally Invasive Surgery Research Center, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shahab Shahabi Shahmiri
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Minimally Invasive Surgery Research Center, Rasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Hage K, Sawma T, Jawhar N, Bartosiak K, Vargas EJ, Abu Dayyeh BK, Ghanem OM. Revisional Bariatric Surgery After Roux-en-Y Gastric Bypass for Bile Reflux: a Single-Center Long-Term Cohort Study. Obes Surg 2024; 34:2420-2430. [PMID: 38861123 DOI: 10.1007/s11695-024-07355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE Revisional bariatric surgery (RBS) after primary Roux-en-Y gastric bypass (RYGB) is indicated for the efficient management of specific complications such as bile reflux. Published literature on this topic remains scarce as we aim to evaluate the long-term outcomes (10 years) of RBS for bile reflux after RYGB. MATERIAL AND METHODS We conducted a single-center retrospective study of patients who underwent primary RYGB complicated by bile reflux and had RBS between 2008 and 2023. Our cohort was divided into two groups based on the etiology of bile reflux. Long-term surgical outcomes and nutritional status were reported and compared between the groups. RESULTS A total of 41 patients (100% primary RYGB; 90.2% female, 97.6% white) were included. 56.1% (n = 23) of patients underwent Roux limb lengthening and the remaining 43.9% (n = 18) had a gastrogastric fistula takedown, with no significant differences in terms of intraoperative complications, estimated blood loss (p = 0.616), length of hospital stay (p = 0.099), and postoperative complications between the two groups. Long-term resolution of obesity-related medical conditions was demonstrated for all the evaluated comorbidities. Lastly, there was no reported mortality, bile reflux recurrence, or micro- and macro-nutrient deficiencies over the total follow-up period of 10 years. CONCLUSION In our cohort, RBS after a primary RYGB for bile reflux management demonstrated safe and efficient short- and long-term surgical outcomes without any reported bile reflux recurrence or mortality. Adequate supplementation and close patient follow-up remain essential to decrease the morbidity and mortality associated with RBS as further studies are required to support our findings.
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Affiliation(s)
- Karl Hage
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tedy Sawma
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Noura Jawhar
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Katarzyna Bartosiak
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, National Research Institute, 04-141, Warsaw, Poland
| | - Eric J Vargas
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA.
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Evans LA, Castillo-Larios R, Cornejo J, Elli EF. Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures. J Clin Med 2024; 13:3104. [PMID: 38892813 PMCID: PMC11172990 DOI: 10.3390/jcm13113104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/15/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.
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Affiliation(s)
| | | | | | - Enrique F. Elli
- Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
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8
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Hsu JL, Farrell TM. Updates in Bariatric Surgery. Am Surg 2024; 90:925-933. [PMID: 38060198 DOI: 10.1177/00031348231220576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.
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Affiliation(s)
- Justin L Hsu
- Department of Surgery, University of Toledo, Toledo, OH, USA
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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9
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Cornejo J, Evans LA, Celik NB, Elli EF. Early Marginal Ulcer After Roux-en-Y Gastric Bypass: MBSAQIP Database Analysis of Trends and Predictive Factors. Obes Surg 2024; 34:1536-1543. [PMID: 38502517 DOI: 10.1007/s11695-024-07179-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE Marginal ulcer (MU) is a known complication after Roux-en-Y gastric bypass (RYGB) that carries significant morbidity. First, we aimed to determine the trends and the rates of readmission, reintervention, and reoperation of 30-day MU. Second, we aim to determine the predictive factors associated with this complication. MATERIALS AND METHODS Patients who had 30-day marginal ulcer (MU) after LRYGB were identified using the 2015-2021 MBSAQIP database. Those who had a 30-day complication other than MU were excluded. Bivariate and logistic regression analyses were performed. RESULTS Among 213,104 patients undergoing laparoscopic RYGB, 638 (0.3%) showed 30-day MU. This group of patients required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Predictive factors for 30-day MU after RYGB were renal insufficiency, history of DVT, previous cardiac stent, African American race, chronic steroid use, COPD, therapeutic anticoagulation, anastomotic leak test, GERD, and operative time > 120 min. Additionally, patients who had 30-day MU showed significantly higher rates of overall complications such as pulmonary, cardiac and renal complications, unplanned ICU admission, blood transfusions, venous thromboembolism (VTE), and non-home discharge (p < 0.05). The MU group showed similar rates of 30-day mortality as those without this complication (0.2% vs 0.1%, p = 0.587). CONCLUSIONS The incidence of 30-day MU following RYGB was 0.3%. Patients with MU required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Some preoperative and intraoperative factors contributed to an increased risk of 30-day MU.
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Affiliation(s)
- Jorge Cornejo
- Department of General Surgery, Mayo Clinic, Jacksonville, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Lorna A Evans
- Department of General Surgery, Mayo Clinic, Jacksonville, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Nafiye Busra Celik
- Department of General Surgery, Mayo Clinic, Jacksonville, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Enrique F Elli
- Department of General Surgery, Mayo Clinic, Jacksonville, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Hage K, Teixeira AF, Surve A, Lind R, Jawad MA, Ghanem M, Abi Mosleh K, Kendrick ML, Cottam D, Ghanem OM. Single anastomosis duodenal switch versus Roux-en-Y gastric bypass in patients with BMI ≥ 50 kg/m 2: a multi-centered comparative analysis. Surg Endosc 2024; 38:2657-2665. [PMID: 38509391 DOI: 10.1007/s00464-024-10765-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) has consistently demonstrated excellent weight loss and comorbidity resolution. However, outcomes vary based on patient's BMI. Single anastomosis duodeno-ileostomy with sleeve (SADI-S) is a novel procedure with promising short-term results. The long-term outcomes of SADI-S in patients with BMI ≥ 50 kg/m2 are not well described. We aim to compare the safety and efficacy of SADI-S with RYGB in this patient population. METHODS We performed a multicenter retrospective study of patients with a BMI ≥ 50 kg/m2 who underwent RYGB or SADI-S between 2008 and 2023. Patient demographics, peri- and post-operative characteristics were collected. Complication rates were reported at 6, 12, 24, and 60 months postoperatively. A multivariate linear regression was used to evaluate and compare weight loss outcomes between both procedures. RESULTS A total of 968 patients (343 RYGB and 625 SADI-S; 68.3% female, age 42.9 ± 12.1 years; BMI 57.3 ± 6.7 kg/m2) with a mean follow-up of 3.6 ± 3.6 years were included. Patients who underwent RYGB were older, more likely to be female, and have a higher rate of sleep apnea (p < 0.001), hypertension (p = 0.015), dyslipidemia (p < 0.001), and type 2 diabetes (p = 0.016) at baseline. The rate of bariatric surgery-specific complications was lower after SADI-S compared to RYGB. We reported no bariatric surgery related deaths after 1 year following both procedures. SADI-S demonstrated statistically higher and sustained weight loss at each time interval compared to RYGB (p < 0.001) even after controlling for multiple confounders. Lastly, the rate of surgical non-responders was lower in the SADI-S cohort. CONCLUSIONS In our cohort, SADI-S was associated with higher and sustained weight-loss results compared to RYGB. Comorbidity resolution was also higher after SADI-S. Both procedures demonstrate a similar safety profile. Further studies are required to validate the long-term safety of SADI-S compared to other bariatric procedures.
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Affiliation(s)
- Karl Hage
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Andre F Teixeira
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr., 1st Floor, Orlando, FL, USA
| | - Amit Surve
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Romulo Lind
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr., 1st Floor, Orlando, FL, USA
| | - Muhammad A Jawad
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr., 1st Floor, Orlando, FL, USA
| | - Muhammad Ghanem
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr., 1st Floor, Orlando, FL, USA
| | | | | | - Daniel Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
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11
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Attia A, Yeluri S, Samuel N, Balchandra S, Vasas P. Intra-Operative Upper GI Endoscopy Helps to Identify the Gastro-Jejunostomy Perforation Site in Roux-en-Y Gastric Bypass Patient. Obes Surg 2024; 34:1993-1994. [PMID: 38564176 DOI: 10.1007/s11695-024-07202-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/22/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Alaa Attia
- Department of Upper GI Surgery, Doncaster & Bassetlaw Teaching Hospitals NHS Trust, Doncaster, DN2 5LT, UK
| | - Sashi Yeluri
- Department of Upper GI Surgery, Doncaster & Bassetlaw Teaching Hospitals NHS Trust, Doncaster, DN2 5LT, UK
| | - Nehemiah Samuel
- Department of Upper GI Surgery, Doncaster & Bassetlaw Teaching Hospitals NHS Trust, Doncaster, DN2 5LT, UK
| | - Srinivasan Balchandra
- Department of Upper GI Surgery, Doncaster & Bassetlaw Teaching Hospitals NHS Trust, Doncaster, DN2 5LT, UK
| | - Peter Vasas
- Department of Upper GI Surgery, Doncaster & Bassetlaw Teaching Hospitals NHS Trust, Doncaster, DN2 5LT, UK.
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12
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Bossen MF, Gormsen J, Kristensen SD, Helgstrand F. Smoking Is Correlated to Internal Hernia After Gastric Bypass Surgery: a Post hoc Analysis of Data from a Randomized Clinical Trial. Obes Surg 2024; 34:1097-1101. [PMID: 38376637 PMCID: PMC11026284 DOI: 10.1007/s11695-024-07097-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/03/2024] [Accepted: 02/07/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Internal herniation is a well-known complication of laparoscopic Roux-en-Y gastric bypass (L-RYGB). The aim of this study was to evaluate smoking as an independent risk factor for internal herniation after L-RYGB. MATERIALS AND METHODS This study was performed as an exploratory post hoc analysis of data from a previous published randomized controlled trial (RCT) designed to compare closure and non-closure of mesenteric defects in patients undergoing L-RYGB. The primary outcome of this study was to assess the significance of smoking as a risk factor for internal herniation after L-RYGB. Secondary outcome was early postoperative complications defined as Clavien-Dindo grade ≥ 2. RESULTS Four hundred one patients were available for post hoc analysis. The risk of internal herniation was significantly higher among patients who were smoking preoperatively (hazard ratio (HR) 2.4, 95% confidence interval (c.i.) 1.3 to 4.5; p = 0.005). This result persisted after adjusting for other patient characteristics (HR 2.2, 1.2 to 4.2; p = 0.016). 6.0% of the patients had postoperative complications within the first 30 days. 4.9% of these patients were smoking and 6.3% were not smoking, p = 0.657. 11.0% of the patients underwent surgery due to internal herniation by 5 years after the primary procedure. CONCLUSION Smoking is a significant risk factor for internal herniation but did not increase risk for 30 days postoperative complications.
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Affiliation(s)
- Marlene F Bossen
- Department of Gastrointestinal and Hepatic Diseases, Surgical Section, Herlev Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - Johanne Gormsen
- Department of Surgery, Zealand University Hospital, 4600, Koege, Denmark
| | - Sara D Kristensen
- Department of Surgery, Zealand University Hospital, 4600, Koege, Denmark
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Hu GH, Pei JB. Progress in understanding of impact of Helicobacter pylori eradication on gastrointestinal microecology. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:216-220. [DOI: 10.11569/wcjd.v32.i3.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2024]
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Jawhar N, Sample JW, Salame M, Marrero K, Tomey D, Puvvadi S, Ghanem OM. The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic. J Clin Med 2024; 13:1878. [PMID: 38610643 PMCID: PMC11012271 DOI: 10.3390/jcm13071878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/16/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.
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Affiliation(s)
- Noura Jawhar
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
| | - Jack W. Sample
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
| | - Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
| | - Katie Marrero
- Carle Foundation Hospital General Surgery Residency, Champaign, IL 61801, USA
| | - Daniel Tomey
- Department of General Surgery, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Suraj Puvvadi
- College of Health Solutions, Arizona State University, Phoenix, AZ 85004, USA
| | - Omar M. Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
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15
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Liang Y, Wang C, Yang L, Yang K, Zhang S, Xie W. Nonsurgical risk factors for marginal ulcer following Roux-en-Y gastric bypass for obesity: a systematic review and meta-analysis of 14 cohort studies. Int J Surg 2024; 110:1793-1799. [PMID: 38320087 PMCID: PMC10942228 DOI: 10.1097/js9.0000000000001042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/20/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUNDS Marginal ulcer (MU) is a common complication of Roux-en-Y Gastric Bypass (RYGB). The primary goal of this meta-analysis was to identify potential risk factors for MU post-RYGB. METHODS A comprehensive literature search was conducted on four databases (PubMed, Embase, Web of Science, and the Cochrane Library) to identify articles published from inception to 23 May 2023 that reported risk factors linked to ulcer occurrence post-RYGB. Hazard Ratio (HR) and Odds Ratio (OR) with respective 95% CI were calculated to estimate the impact of selected risk factors on MU. The risk factors were evaluated through multivariate analyses. The estimated risk factors were subjected to a random-effects model. Subgroup analysis based on study baseline characteristics and leave-one-out sensitivity analysis were also performed to investigate the potential sources of heterogeneity and assess the robustness of the findings. RESULT Herein, 14 observational studies involving 77 250 patients were included. Diabetes, smoking, and steroid use were identified to be risk factors of MU, with pooled ORs of (1.812; 95% CI: 1.226-2.676; P =0.003), (3.491; 95% CI: 2.204-5.531; P< 0.001), and (2.804; 95% CI: 1.383-5.685; P =0.004), respectively. Other risk factors, such as alcohol consumption, male sex, and PPI use, were deemed not significant due to differences in data acquisition and effect estimates. CONCLUSION Diabetes, smoking, and steroid use were identified as independent risk factors of MU. Enhancing awareness of these identified risk factors will lead to more effective preoperative prevention and targeted postoperative interventions for patients undergoing RYGB.
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Affiliation(s)
| | | | | | | | | | - Wenbiao Xie
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, People’s Republic of China
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16
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Higa K. Surgical Management of Bariatric Complications and Weight Regain. Gastroenterol Clin North Am 2023; 52:707-717. [PMID: 37919022 DOI: 10.1016/j.gtc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
The history and evolution of bariatric/metabolic surgical procedures allows for only a brief introduction to complications and surgical approaches for improved weight loss. Our specialty lacks standardization of our operations such as gastric pouch size, intestinal bypass lengths, and consensus on which procedure is best for each individual patient. Anatomic construct as well as adherence to lifestyle modifications can affect short- and long-term outcomes.
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Abi Mosleh K, Belluzzi A, Salame M, Kendrick ML, Abu Dayyeh BK, McKenzie TJ, Ghanem OM. Long-Term Outcomes of Bariatric Surgery in Patients on Chronic Anticoagulation. Obes Surg 2023; 33:4007-4016. [PMID: 37917392 DOI: 10.1007/s11695-023-06910-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Approximately 3% of patients undergoing metabolic and bariatric surgery (MBS) are receiving chronic anticoagulation therapy (CAT) prior to operation. The management of these patients is complex, as it involves balancing the potential risk of thrombosis against that of bleeding. Our primary objective is to assess the long-term bleeding risk in patients undergoing MBS. We also aim to observe the trends in anticoagulant dosing after MBS. METHODS A single-center retrospective review of patients who underwent either primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with preoperative CAT between 2008 and 2022 was performed. Data on baseline demographics, indication for anticoagulation, type of CAT, and dosing were collected. Events of bleeding and the CAT at event were subsequently evaluated. RESULTS A total of 132 patients (82 RYGB and 50 SG) initially on CAT were identified, with atrial fibrillation being the most common indication. Incidence of long-term bleeding was significantly higher in the RYGB group (18.3%) compared to the SG group (4%) (p = 0.017) over a total of 5.2 ± 3.8 years. Bleeding marginal ulcer (MU) was the most common cause of bleeding in the RYGB group (13.4%). 84.2% of all bleeding events occurred in patients on chronic Warfarin therapy. CONCLUSION Long-term CAT is associated with an increased risk of bleeding in RYGB patients, particularly MU bleeds. Patients on CAT seeking MBS should be counseled regarding this risk and potential implications. Direct-acting oral anticoagulants offer promise as an alternative to Warfarin in these patients; further research is necessary to better understand their safety.
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Affiliation(s)
- Kamal Abi Mosleh
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amanda Belluzzi
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Marita Salame
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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18
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Cheng V, Samakar K, Dobrowolsky AB, Nguyen JD, Abel SA, Pakula A, Bernard A, Martin MJ. Common postbariatric surgery emergencies for the acute care surgeon: What you need to know. J Trauma Acute Care Surg 2023; 95:817-831. [PMID: 37982794 DOI: 10.1097/ta.0000000000004125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
ABSTRACT The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
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Affiliation(s)
- Vincent Cheng
- From the Division of Trauma and Surgical Critical Care (V.C., M.J.M.), Los Angeles County + USC Medical Center, University of Southern California; Division of Upper GI and General Surgery (V.C., K.S., A.B.D., J.D.N., S.A.A., M.J.M.), Keck School of Medicine of the University of Southern California, Los Angeles; Surgical Specialties (A.P.), Simi Valley Adventist Hospital, Simi Valley, California; and Division of Acute Care Surgery and Trauma (A.B.), University of Kentucky-Lexington, Lexington, Kentucky
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Salame M, Teixeira AF, Lind R, Ungson G, Ghanem M, Abi Mosleh K, Jawad MA, Abu Dayyeh BK, Kendrick ML, Ghanem OM. Marginal Ulcer and Dumping Syndrome in Patients after Duodenal Switch: A Multi-Centered Study. J Clin Med 2023; 12:5600. [PMID: 37685666 PMCID: PMC10488365 DOI: 10.3390/jcm12175600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The current design of biliopancreatic diversion with duodenal switch (BPD/DS) and single anastomosis duodenal-ileal bypass with sleeve (SADI-S) emphasizes the importance of the pylorus' preservation to reduce the incidence of marginal ulcer (MU) and dumping. However, no institutional studies have yet reported data on their prevalence. We aimed to assess the incidence of MU and dumping after duodenal switch (DS) and identify the associative factors. METHODS A multi-center review of patients who underwent BPD/DS or SADI-S between 2008 and 2022. Baseline demographics, symptoms, and management of both complications were collected. Fisher's exact test was used for categorical variables and the independent t-test for continuous variables. RESULTS A total of 919 patients were included (74.6% female; age 42.5 years; BMI 54.6 kg/m2) with mean follow-up of 31.5 months. Eight patients (0.9%) developed MU and seven (0.8%) had dumping. Patients who developed MU were more likely to be using non-steroidal anti-inflammatory drugs (NSAID) (p = 0.006) and have a longer operation time (p = 0.047). Primary versus revisional surgery, and BDP/DS versus SADI-S were not associated with MU or dumping. CONCLUSIONS The incidences of MU and dumping after DS were low. NSAID use and a longer operation time were associated with an increased risk of MU, whereas dumping was attributed to poor dietary habits.
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Affiliation(s)
- Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Romulo Lind
- Department of Surgery, Orlando Health, Orlando, FL 32806, USA
| | - Gilberto Ungson
- Department of Surgery, Cima Hospital, Hermosillo 83280, Mexico
| | - Muhammad Ghanem
- Department of Surgery, Orlando Health, Orlando, FL 32806, USA
| | | | | | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Omar M. Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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20
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Salame M, Jawhar N, Belluzzi A, Al-Kordi M, Storm AC, Abu Dayyeh BK, Ghanem OM. Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management. J Clin Med 2023; 12:4336. [PMID: 37445371 DOI: 10.3390/jcm12134336] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.
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Affiliation(s)
- Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Noura Jawhar
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Amanda Belluzzi
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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