Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center

Nonsteroidal anti-inflammatory drug (NSAID) prescribing after gastrojejunostomy: A preventable cause of morbidity

OBJECTIVE

Study findings showing an association between nonsteroidal anti-inflammatory drug use and marginal ulcer, a significant cause of morbidity after gastrojejunostomy, have been inconsistent. This study aimed to evaluate this relationship in large cohort.

METHODS

This retrospective cohort included adult patients with a history of gastrojejunostomy documented between 2004 and 2023. The electronic medical record was queried for nonsteroidal anti-inflammatory drug prescriptions, marginal ulcer diagnosis, and comorbidities. Multivariable logistic regression was performed to assess the association between marginal ulcer and nonsteroidal anti-inflammatory drug exposures, controlling for smoking, Helicobacter pylori history, acid-suppressing therapy, diabetes, age, and sex.

RESULTS

During the study period, 6,888 patients with a history of gastrojejunostomy were identified, of whom 45.2% (n = 3,115) of patients were exposed to an nonsteroidal anti-inflammatory drug and 10.12% (n = 697) developed a marginal ulcer. On multivariable analysis, the risk of marginal ulcer was found to be dose-dependent, with increasing odds of marginal ulcer with an increasing number of nonsteroidal anti-inflammatory drug exposures from odds ratio 1.67 (95% confidence interval, 1.37-2.02) with 1-2 nonsteroidal anti-inflammatory drug exposures to odds ratio 2.42 (95% confidence interval, 1.79-3.24) with >8 nonsteroidal anti-inflammatory drug exposures. Acid-suppressing therapy was found to be protective (odds ratio, 0.61; 95% confidence interval, 0.52-0.73). Over the last decade, the number of nonsteroidal anti-inflammatory drugs prescribed to patients with gastrojejunostomy has significantly increased from 15.87 prescriptions per 1,000 patients per year to 531.02 per 1,000 patients per year (R2 = 0.91, P < .001).

CONCLUSION

Marginal ulcer after gastrojejunostomy is associated with nonsteroidal anti-inflammatory drug prescriptions in a dose-dependent manner. Although acid-suppressing therapy appears protective for marginal ulcer, quality improvement efforts should focus on diminishing nonsteroidal anti-inflammatory drug prescribing in this population.

ASMBS literature review on the treatment of marginal ulcers after metabolic and bariatric surgery

Marginal ulcers (MUs) encompass a group of mucosal disruptions and subsequent inflammatory changes and their sequala found after Roux-en-Y gastric bypass (RYGB) oneanastomosis gastric bypass (OAGB), and, less commonly, after biliopancreatic diversion with duodenal switch (BPD/DS) or single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). Prevalence of MU after RYGB ranges from .6%-16%. This review summarizes the current knowledge about the treatment options available for MU after MBS for providers who treat them.

The Relevance of Gastroscopy in the Diagnostic Work-up for Marginal Ulceration in Patients Presenting with Abdominal Pain Following Laparoscopic Roux-en-Y Gastric Bypass

INTRODUCTION AND PURPOSE

It is unknown what the incidence of gastroscopy-diagnosed marginal ulceration is, while gastroscopy is a frequently chosen diagnostic modality in patients presenting with abdominal pain with a Roux-en-Y gastric bypass (RYGB) in history. The aim of this study was to examine the incidence and treatment of gastroscopy-diagnosed marginal ulceration in patients presenting with the first episode of abdominal pain after RYGB, in which gastroscopy is chosen as the first step in the diagnostic work-up.

MATERIAL AND METHODS

A post hoc analysis was performed of a prospective cohort of 2273 patients undergoing RYGB between 2014 and 2019 in a large non-academic hospital with a dedicated bariatric unit. All patients presenting with abdominal pain > 30 days postoperatively were included. Primary outcome was gastroscopy identified marginal ulceration and treatment.

RESULTS

One hundred two out of 498 patients presenting with abdominal pain after RYGB (20%) underwent gastroscopy as the first diagnostic step. In 84% of these patients, no marginal ulcer was found. Marginal ulceration was observed in 16/102 patients (16%). All patients underwent optimization of PPI treatment and lifestyle advises. Seven patients underwent revisional surgery, at a median of 163 days (range 80-1287) after diagnosis.

CONCLUSION

In a minority of patients undergoing gastroscopy for abdominal pain post-RYGB, a marginal ulceration is identified. Revisional surgery is rarely needed in all patients undergoing gastroscopy and only performed after several months when complaints persist despite PPI optimization. Only performing gastroscopy when symptoms persist safely reduces the number of gastroscopy for abdominal pain after RYGB.

Nutritional Challenges and Treatment After Bariatric Surgery

Bariatric surgery is an important weight loss tool in individuals with severe obesity. It is currently the most effective long-term weight loss treatment that lowers obesity-related comorbidities. It also has significant physiological and nutritional consequences that can result in gastrointestinal complications and micronutrient deficiencies. After gastric bypass, clinical events that negatively affect nutritional status include malabsorption, dumping syndrome, kidney stones, altered intestinal bile acid availability, bowel obstruction, ulcers, gastroesophageal reflux, and bacterial overgrowth. Risk factors for poor nutritional status and excessive loss of lean body mass and bone include reduced dietary quality and inadequate intake, altered nutrient absorption, and poor patient compliance with nutrient supplementation. There are unique concerns in adolescents, older individuals, and individuals who become pregnant postoperatively. With careful management, health-care professionals can assist with long-term weight loss success and minimize the risk of acute and long-term nutrition complications after bariatric surgery.

Marginal Ulcer Perforation after One Anastomosis Gastric Bypass: Surgical Treatment and Two-Year Outcomes

Background: Marginal ulcer (MU) perforation is a chronic complication after One-anastomosis Gastric Bypass (OAGB). This study's purpose was to analyze patients undergoing OAGB revision due to MU perforation and describe the two-year outcomes. Methods: A retrospective analysis of a database in a single-tertiary hospital. All patients undergoing surgical revision due to MU perforation were included. Results: During the study period, 22 patients underwent OAGB revision due to MU perforation. The rate of MU perforation was 0.98%. The median age was 48 years and there were 13 men (59%). The median time from OAGB to MU perforation was 19 months with a median total weight loss of 31.5%. Nine patients (41%) were smokers. Omental patch (±primary closure) was performed in 19 patients (86%) and three patients (14%) underwent conversion to Roux-en-Y gastric bypass (RYGB). At a median follow-up of 48 months, three patients (14%) had recurrent MU diagnosis, of which one had a recurrent MU perforation. Four patients (18%) underwent conversion to RYGB during follow-up. Conclusions: MU perforation is a chronic complication after OAGB. In this cohort, most patients were men and likely to be smokers. Omental patch was effective in most cases. Recurrent MU rates at two years follow-up were acceptable.

Is open-capsule proton pump inhibitor associated with faster healing time for marginal ulceration after Roux-en-Y gastric bypass?

BACKGROUND

Marginal ulceration (MU) is a significant cause of morbidity after Roux-en-Y gastric bypass (RYGB). Proton pump inhibitors (PPIs) are the primary treatment. Prior limited data suggest that open-capsule PPIs (OC-PPIs) improve MU healing compared with intact-capsule PPIs (IC-PPIs), necessitating further validation.

OBJECTIVES

We aimed to compare healing times of MU after RYGB when treated with OC-PPIs versus IC-PPIs.

SETTING

Tertiary academic center, United States.

METHODS

We retrospectively analyzed patients with prior RYGB diagnosed with MU from 2012 to 2022. Patients requiring mechanical closure without documented healing and without clear PPI prescriptions were excluded. The primary outcome was time to ulcer healing. Log-rank testing and Kaplan-Meier survival curve analyses were performed to compare MU healing times when treated with OC-PPIs versus IC-PPIs. Subgroup analyses further characterized ulcer healing times based on type and dosage of PPI used.

RESULTS

A total of 108 patients were included for final analysis (38 received OC-PPIs and 70 received IC-PPIs). Treatment with OC-PPIs significantly decreased MU healing time compared with IC-PPIs (146.18 versus 226.14 d; p = .018). However, when stratified by PPI potency, the positive effect of opening the capsule lost significance.

CONCLUSION

In this study, OC-PPIs significantly improved MU healing times compared with IC-PPIs in RYGB patients, consistent with prior data. However, on subgroup analysis comparing therapy with similar PPI potency, the MU healing time did not differ with respect to administration method. These results highlight the need for a prospective randomized trial to compare the true effect of administration method.

Comparative evaluation of early diabetic outcomes in southeast asian patients with type 2 diabetes mellitus undergoing Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (LSG)

Obesity and type 2 diabetes mellitus (T2DM) is an alarming problem globally and a growing epidemic. Metabolic surgery has been shown to be successful in treating both obesity and T2DM, usually after other treatments have failed. This study aims to compare Roux-Y gastric bypass and sleeve gastrectomy in determining early diabetic outcomes in obese Malaysian patients with T2DM following surgery. A total of 172 obese patients with T2DM who were assigned to either laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were analysed up to a year post-procedure. The patients' T2DM severity were stratified using the Individualized Metabolic Surgery (IMS) score into mild, moderate and severe. Remission rates of diabetes were compared between surgical techniques and within diabetic severity categories. T2DM remission for patients who underwent either surgical technique for mild, moderate or severe disease was 92.9%, 56.2% and 14.7% respectively. Both surgical techniques improved T2DM control for patients in the study. Comparing baseline with results 1 year postoperatively, median HbA1c reduced from 7.40% (IQR 2.60) to 5.80% (IQR 0.80) (p < 0.001), mean total antidiabetic medications use reduced from 1.48 (SD 0.99) to 0.60 (SD 0.86) [p < 0.001], insulin usage reduced from 27.9 to 10.5% (p < 0.001), and T2DM control improved from 27.9 to 82% (p < 0.001). The patients had a median excess BMI loss of 69.4% (IQR 34%) and 53.2% (IQR 36.0%) for RYGB and SG respectively (p = 0.016). At one year following surgery, there is no difference between LRYGB and LSG in terms of diabetic remission. LSG is not inferior to LRYGB in terms of early diabetic outcomes. Milder T2DM shows a better response. LSG is a simpler procedure with a lower risk profile and should be considered as an early treatment option for obese patients with T2DM.

Rates of Recurrent Marginal Ulcer in Gastric Bypass Patients Undergoing Revisional Surgery

INTRODUCTION

The rate of marginal ulcer (MU) following primary Roux-en-Y Gastric Bypass (RYGB) is approximately .6-16%. Few studies have evaluated recurrence rates following surgical revision for MU. The primary aim of this study was to determine the rate of MU recurrence following revision. The secondary aim was to evaluate the impact of truncal vagotomy (TV) on the recurrence rates and analyze potential risk factors associated with the recurrence of MU after revision.

METHODS

We conducted a retrospective cohort study examining data at a single tertiary academic medical center. Adult patients with a history of RYGB who underwent gastrojejunostomy revision for recurrent MU between the years of 2003-2020 were included. We sought to determine our overall rate of MU following revision, with and without TV. Additionally, we examined the association of risk factors with MU recurrence. Fisher's exact test was used to determine the statistical significance of recurrence rates between the groups.

RESULTS

We included 90 patients in the study. The overall recurrence rate for MU was 16.7%. Of the 90 patients, 35 (35.4%) patients underwent TV at the time of revision. The recurrence rate of MU after GJ revision with TV was 14.3% in comparison to those without TV, 18.2% (P = .775). Smoking, steroid, alcohol use, history of cardiac surgery/intervention, and helicobacter pylori were not significantly associated with recurrent MU following revision.

CONCLUSIONS

The rate of recurrence after revision for MU is high. Adding TV trended towards decreased MU recurrence after revisional surgery, however not significant. Larger studies are needed to evaluate risk factors associated with recurrent MU after revision.

Proton pump inhibitor prophylaxis after Roux-en-Y gastric bypass: A national survey of surgeon practices

BACKGROUND

Proton pump inhibitors (PPIs) are frequently used after Roux-en-Y gastric bypass (RYGB) to prevent marginal ulceration. The optimal duration of PPI treatment after surgery to minimize ulcer development is unclear.

OBJECTIVES

Assess bariatric surgeon practice variability regarding postoperative PPI prophylaxis.

SETTING

Survey of medical directors of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited centers.

METHODS

Members of the American Society for Metabolic and Bariatric Surgery research committee developed and administered a web-based anonymous survey in November 2021 to bariatric surgeons of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited programs detailing questions related to surgeons' use of PPI after RYGB including patient selection, medication, dosage, and treatment duration.

RESULTS

The survey was completed by 112 surgeons (response rate: 52.6%). PPIs were prescribed by 85.4% of surgeons for all patients during their hospitalization, 3.9% for selective patients, and 10.7% not at all. After discharge, 90.3% prescribed PPIs. Pantoprazole was most often used during hospitalization (38.5%), while omeprazole was most prescribed (61.7%) after discharge. The duration of postoperative PPI administration varied; it was 3 months in 43.6%, 1 month in 20.2%, and 6 months in 18.6% of patients. Finally, surgeons' practice setting and case volume were not associated with the duration of prophylactic PPI administration after RYGB.

CONCLUSIONS

PPI administration practices vary widely among surgeons after RYGB, which may be related to the limited comparative evidence and guidelines on best duration of PPI administration. Large prospective clinical trials with objective outcome measures are needed to define optimal practices for PPI prophylaxis after RYGB to maximize clinical benefit.

Propensity score matching analysis comparing outcomes between primary and revision Roux-en-Y gastric bypass after adjustable gastric banding: a retrospective record-based cohort study

BACKGROUND

One-stage revision Roux-en-Y gastric bypass (RRYGB) after Laparoscopic adjustable gastric banding (LAGB) is widely adopted, but its safety is still debated.

OBJECTIVE

This study aimed to compare outcomes between primary Roux-en-Y gastric bypass (PRYGB and RRYGB after LAGB.

METHOD

A retrospective record-based cohort study of patients who underwent PRYGB and RRYGB for failed LAGB and completed at least 2 years of follow-up from 2008 to 2019. Propensity score matching (PSM) analysis was conducted to obtain a balanced sample of patients with RRYGB and PRYGB interventions by adjusting for baseline covariates including age and sex.

RESULTS

Patients with PRYGB (n = 558) and RRYGB (n = 156) were included. PSM identified 98 patients for RRYGB and 98 patients for PRYGB. Both cohorts exhibited significant reductions in BMI compared to baseline values (p < 0.001), but reductions were significantly higher in PRYGB compared to those in RRGYB at 6 months (- 10.55 ± 8.54 vs. - 8.38 ± 5.07; p = 0.032), 1-year (- 21.50 ± 8.19 vs. 16.14 ± 6.93; p < 0.001), and 2 years (- 24.02 ± 7.85 vs. - 18.93 ± 6.80; p < 0.001), respectively. A significant improvement in food tolerance from the 1st to the 2nd year was seen after RYGB (p < 0.001). The rates of early and late complications were similar in both cohorts (p = 0.537, p = 1.00). Overall re-intervention rates were 5.1 and 3.1% for RRYGB and PRYGB p = 0.721). Both cohorts exhibited significant improvement in comorbidities after 2 years (p < 0.001).

CONCLUSIONS

One-stage RRYGB for failed LAGB is safe and effective with comparable rates of complications, re-interventions, and resolution of associated comorbid conditions compared to PRYGB.

Revision Gastrojejunostomy Versus Suturing With and Without Omental Patch for Perforated Marginal Ulcer Treatment After Roux-en-Y Gastric Bypass

BACKGROUND

Ulceration at the gastrojejunostomy is a late bariatric surgery complication in 0.6-16% of Roux-en-Y gastric bypass (RYGB) patients. As there is no general consensus on management of acute ulcer perforations, we compare two methods of surgical repair: the most commonly performed procedure, suturing of ulcer with or without omental patch versus revision gastrojejunostomy (RG).

METHODS

A retrospective chart review of cases at a single large, Midwestern US high-volume bariatric center from November 2, 2006 through March 11, 2021 identified 144 RYGB patients undergoing surgical repair for a perforated ulcer: 72 treated by SGP and 72 by RG. Outcomes, including length of stay, leaks, readmissions, and reoperations, were compared. Categorical variables were compared by Chi-square tests and continuous variables by ANOVA.

RESULTS

Patients were primarily female (77.1%) and Caucasian (97.2%), 49.7 ± 12.5 years old, and 90.6 ± 26.6 kg. Most had laparoscopic RYGBs (98.6%). There were no demographic differences between groups. Of the RG patients, 11.4% experienced ulcer recurrence versus 41.7% of SGP patients (p < .001), and 2.8% of RG versus 11.1% of SGP patients required a reversal (p < .05). No significant differences between groups occurred in time to perforation (3.2 vs. 2.5 years for RG and SGP groups, respectively), length of stay (5.0 vs. 6.8 days), leaks (1.4% vs. 2.8%), readmissions (4.2% vs. 4.2%), or reoperations (2.8% vs 5.6%).

CONCLUSIONS

Patients developing perforated marginal ulcers after RYGB can be safely and effectively treated by revision gastrojejunostomy with a lower likelihood of ulcer recurrence. Short-term morbidity was comparable to suturing with or without an omental patch.

Management strategies of anastomotic ulcer after gastric bypass and risk factors of recurrence

BACKGROUND

Marginal ulcers (MU) after gastric bypass are a challenging problem. The first-line treatment is a medical therapy with eviction of risk factors but is sometimes insufficient. The management strategies of intractable ulcers are still not clearly defined. The aim of our study was to analyse the risk factors for recurrence, the management strategies used and their efficiencies.

METHODS

Based on a retrospective analysis of all MU managed in our tertiary care centre of bariatric surgery during the last 14 years, a descriptive analysis of the cohort, the management strategies and their efficiency were analysed. A logistic regression was done to identify the independent associated risk factors of intractable ulcer.

RESULTS

Fifty-six patients matched inclusion criteria: 30 were referred to us (13 Roux-en-Y Gastric Bypass-RYGB and 17 One Anastomosis Gastric Bypass-OAGB), 26 were operated on in our institution (24 RYGB and 2 OAGB). 11 patients had a complicated inaugural MU requiring an interventional procedure in emergency: 7 perforations, 4 haemorrhages. The majority of MU were treated medically as a first-line therapy (n = 45; 80.4%). 32 MU recurred: 20 patients required surgery as a 2nd line therapy, 6 were operated on as a 3rd line therapy and 1 had a surgery as a 5th line therapy. The OAGB was the only risk factor of recurrence (p = 0.018). We found that the Surgical management was significantly more frequent for patients with a OAGB (84% versus 35% for RYGB, p = 0.001); the most performed surgical procedure was a conversion of OAGB to RYGB (n = 11, 37.9%).

CONCLUSION

Surgery was required for a large number of MU especially in case of recurrence, but recurrence can still occur after the surgery. The OAGB was the only risk factor of recurrence identified and conversion to RYGB seemed to be effective for the healing.

Comparison of 5-Year Follow-up Outcomes Between Primary and Revision Roux-en-Y Gastric Bypasses After Open Vertical Banded Gastroplasty: an Inverse Propensity Score-Weighted Analysis

INTRODUCTION

Vertical banded gastroplasty (VBG) is associated with high weight regain; Roux-en-Y gastric bypass (RYGB) is used as a revision procedure in patients with VBG experiencing weight regain. This study compared the 5-year follow-up outcomes of primary (PRYGB) and revision RYGB after VBG (RRYGB).

METHODS

Patients who underwent PRYGB or RRYGB after VBG from 2008 to 2016 were enrolled. Data on weight regain, weight loss (WL), food tolerance (FT), early and late complications, and resolution or improvement in associated medical conditions were analyzed.

RESULTS

PRYGB and RRYGB groups had 558 and 156 patients, respectively, after exclusion of the lost to follow-up patients. PRYGB group showed significantly lower mean body mass index (over the entire follow-up period), early complications, reintervention rates for late complications, and overall reintervention rates than that of the RRYGB group. On the other hand, FT scores, odds of late complications, and improvements (in the fifth year) in associated medical conditions were comparable between the two groups.

CONCLUSION

RRYGB in patients with VBG who regained weight showed comparable safety and resolution of associated diseases to that of PRYGB over the 5-year follow-up period. The WL in the RRYGB group was acceptable despite being less than that of the PRYGB group. FT was better after RRYGB than that of PRYGB in the first year; however, both were comparable at the fifth year follow-up. Patients with VBG undergoing RYGB should receive attentive treatment and evaluation of associated factors.

Postprocedural Gastrointestinal Emergencies

Postprocedural complications encompass a wide array of conditions that vary in acuity, symptoms, index procedure, and treatment. Continued advancements in diagnostic and therapeutic procedures have led to a significant shift of procedures to the ambulatory setting. This trend is of particular interest to the emergency physician, as patients who develop complications often present to an emergency department for evaluation and treatment. Here the authors examine a high-yield collection of procedures, both ambulatory and inpatient, notable for their frequent utilization and unique complication profiles including common laparoscopic surgical procedures, bariatric surgery, endoscopic procedures, interventional radiology procedures, and hernia repairs with implantable mesh.

Management of Postoperative Complications Following Bariatric and Metabolic Procedures

Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.

Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.

Laparoscopic Gastric Bypass: Still the Gold Standard?

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another.

Incidence and Prognostic Factors for the Development of Symptomatic and Asymptomatic Marginal Ulcers After Roux-en-Y Gastric Bypass Procedures

INTRODUCTION

Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU.

METHODS

All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively.

RESULTS

In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m². The median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58-26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively.

CONCLUSION

MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

The use of nonsteroidal anti-inflammatory drugs after sleeve gastrectomy

BACKGROUND

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is discouraged after bariatric surgery. The effect of NSAIDs on patients who have undergone sleeve gastrectomy (SG) is not well studied. Moreover, the rate of NSAID use after SG is unknown.

OBJECTIVES

To determine the rate of NSAID use after SG, and its associated complications.

SETTING

A single institution, multi-surgeon, academic, tertiary care hospital.

METHODS

We performed a retrospective review of patients who underwent SG between January 1, 2014, and November 1, 2017. A phone interview was conducted with identified patients. The inclusion criteria were any patient who had undergone SG during the study period, and there were no exclusion criteria.

RESULTS

We identified 421 SG patients for inclusion. There were 231 phone surveys completed, with 64.5% of respondents reporting some NSAID use after SG. Of the respondents who used NSAIDs, 40.3% reported that they used the drugs often (>once/wk), 28.2% reported occasional use (>once/mo but <once/wk), and 31.5% reported rare use (<once/mo). Nearly 26% of phone interview respondents regularly used NSAIDs after SG. A retrospective review of the 421-patient cohort revealed 0 cases of sleeve complications secondary to NSAID use when searching for incidences of bleeding, ulceration, gastritis, gastropathy, perforation, leak, or stenosis.

CONCLUSION

NSAID use in our bariatric surgery population is high despite an institutional policy to prohibit their use across all bariatric patients. Despite the high incidence of NSAID use in our patient population, we could not identify a single case of an NSAID-induced gastrointestinal complication in our retrospective review. NSAID use after SG may be a safe and viable pain management strategy that needs further evaluation.

Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review

BACKGROUND

There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures.

METHODS

PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies.

RESULTS

Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications.

CONCLUSION

This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.

Low Risk for Marginal Ulcers in Duodenal Switch and Gastric Bypass in a Well-Defined Cohort of 472 Patients

PURPOSE

Marginal ulcer (MU) is well-known complication in bariatric surgery. Several studies are available in Roux-en-Y gastric bypass (RYGBP), while data on the incidence in duodenal switch (DS) is limited. We aimed to compare the incidence of MU between DS and RYGBP in a well-defined cohort and to identify associative factors.

METHODS

A cohort of 732 patients with BMI ≥ 48 who had undergone primary DS or RYGBP during 2008-2018 received a questionnaire concerning ulcers, PPI therapy, and smoking habits; hereafter, patient charts were reviewed. Incidence rates (IRs) for MU were calculated in our survey and on previous registered data in the national quality register for bariatric surgery (SOReg). A multivariate regression analysis was performed to identify predictive risk factors for MU.

RESULTS

After a mean follow-up of 6.1 years, 472 (64%) patients responded (47 ± 11 years old, 65% women and 42% DS). Of 41 MUs identified, 23 were endoscopically verified. Gastrointestinal bleeding, abdominal pain, and dysphagia were the most common symptoms. IR for MU was 1.4% (DS 1.3% and RYGBP 1.5%) per patient-year, compared with 0.9% according to SOReg-data. Persisting PPI treatment was seen in about three quarter of former MU patients (OR 11.2 [3.6-34.7], p < 0.001), but no other associative factors were found.

CONCLUSION

The overall risk for MU was low, about 1% per patient-year, without difference between DS and RYGBP. Ongoing PPI treatment was frequent in many former MU patients. This study on MU after DS provides reassuring results for future bariatric surgery candidates.

A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity

PURPOSE

Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO).

METHOD

The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies.

RESULTS

Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76).

CONCLUSION

In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.

Endoscopic Management of Recalcitrant Marginal Ulcers by Covering the Ulcer Bed

BACKGROUND

Management options for marginal ulcers (MU) vary from medical therapy to revision surgery. Medical therapy is often ineffective and revision surgery is associated with a high morbidity and possible recurrence.

AIMS

To evaluate technical feasibility, efficacy, and safety of endoscopic management of MU by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent (FCSEMS).

METHODS

Medical records of consecutive patients who underwent endoscopic suturing and/or FCSEMS deployment for recalcitrant MU between August 2016 and June 2017 at a single academic center were reviewed. Recalcitrant MU was defined as an ulcer that persists after 6 to 8 weeks despite maximal medical therapy (open capsule PPI, 40 mg bid as well as sucralfate qid), cessation of smoking and nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori eradication.

RESULTS

Eleven patients (age range 31-60; all females) with mean BMI of 27.72 ± 5.93 kg/m² underwent endoscopic suturing and/or stent deployment for recalcitrant MU with abdominal pain at a median of 50 months (range 3-120) post-Roux-en-Y gastric bypass (RYGB). Seven patients were managed by oversewing, two were managed by FCSEMS, and two patients required both. Technical success was 100%. All patients reported resolution of abdominal pain at 1 week. Surveillance endoscopy performed in 10/11 (90.9%) patients at 8 weeks revealed complete ulcer healing in 9/10 (90%). No adverse events were reported.

CONCLUSION

Endoscopic management is an effective and safe method to treat MU and should be considered an alternative to surgical revision. It appears effective for perforated and recalcitrant MU.

Metabolic Surgery as a Treatment Option for Type 2 Diabetes Mellitus: Surgical View

PURPOSE OF REVIEW

Type 2 diabetes mellitus (T2DM) is increasing in prevalence and associated with numerous metabolic complications leading to increased mortality and costs. Metabolic surgery, or surgery to treat T2DM and obesity, is effective at achieving remission from T2DM. This review discusses the most commonly used surgical options including the adjustable gastric band, the Roux-en-Y gastric bypass, the sleeve gastrectomy, and the biliopancreatic diversion with duodenal switch and their ability to treat and prevent T2DM.

RECENT FINDINGS

There is an increasing body of literature that justifies the inclusion of metabolic surgery into the treatment algorithm for patients with obesity and T2DM. Metabolic procedures should be performed at centers that offer comprehensive treatment of metabolic disorders and have expertise in gastrointestinal surgery. The incremental improvement in the quality and safety of metabolic surgery has significantly reduced the risk of serious post-operative complications. Metabolic surgery is a safe and effective treatment option for obese patients with T2DM.

Evaluation of the rate of marginal ulcer formation after bariatric surgery using the MBSAQIP database

BACKGROUND

Marginal ulcer (MU) formation is a known problem after gastric bypass. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database contains data from all US and Canadian Centers of Excellence including complication rates. We hypothesized that the short-term rate of ulceration is low.

METHODS

We queried the MBSAQIP database for the year 2015. We searched patients with primary gastric bypass who developed MU. We then compared preoperative, operative, and postoperative characteristics with patients who did not develop MU.

RESULTS

The incidence of MU in the entire cohort of GB patients was 155 of 44,379 (0.35%, 95% CI 0.297%, 0.409%). Among the 155 patients with an ulcer, 88 (57%) patients had only one procedure, 69 had an intervention (therapeutic or diagnostic endoscopy), 16 had readmission, and 3 had reoperation. 65 patients (42%) had two procedures with the majority having both readmissions and endoscopy (n = 59); and two patients (1%) had three procedures. Ulcer formation was most common in the intervention group (11.4%). The occurrence of ulcer formation was associated with unplanned ICU admissions (6.45%), transfusions (5.16%), postoperative UTI (3.87%), sepsis (1.94%), and myocardial infarction (0.65%). Death occurred in 76 patients with no related cases to MUs. The risk of ulcer was associated with increased BMI (OR 1.02, p = 0.01), presence of percutaneous transluminal cardiac catheterization (PTC) (2.17, p = 0.038), histories of DVT (1.72, p = 0.085), and pulmonary embolism (2.84, p = 0.002).

CONCLUSIONS

In a nationally reported database, symptomatic MUs rarely occur in the first month. The large majority are diagnosed and treated endoscopically with minimal need for surgical intervention. The risk of anastomotic ulcer was increased with increased BMI, need for PTC, and history of DVT/PE.

Thoracoscopic truncal vagotomy versus surgical revision of the gastrojejunal anastomosis for recalcitrant marginal ulcers

INTRODUCTION

Marginal ulcer is a common complication following Roux-en-Y gastric bypass with incidence rates between 1 and 16%. Most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. Revision of the gastrojejunal (GJ) anastomosis carries significant morbidity with complication rates ranging from 10 to 50%. Thoracoscopic truncal vagotomy (TTV) may be a safer alternative with decreased operative times. The purpose of this study is to evaluate the safety and effectiveness of TTV in comparison to GJ revision for treatment of recalcitrant marginal ulcers.

METHODS

A retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from 1 September 2012 to 1 September 2017. All underwent medical therapy along with lifestyle changes prior to intervention and had preoperative EGD that demonstrated a recalcitrant marginal ulcer. Revision of the GJ anastomosis or TTV was performed. Data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate.

RESULTS

Twenty patients were identified who underwent either GJ revision (n = 13) or TTV (n = 7). There were no 30-day mortalities in either group. Mean operative time was significantly lower in the TTV group in comparison to GJ revision (95.7 ± 16 vs. 227.5 ± 89 min, respectively, p = 0.0022). Recurrence of ulcer was not significant between groups and occurred following two GJ revisions (15%) and one TTV (14%). Complication rates were not significantly different with 62% in the GJ revision group and 57% in the TTV group. Approximately 38% (5/13) of GJ revisions and 28% (2/7) of TTV patients experienced complications with Clavien-Dindo scores > 3. There was no difference in postoperative symptoms between both groups.

CONCLUSIONS

Our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. However, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups.

Metabolic and Bariatric Surgery: An Effective Treatment Option for Obesity and Cardiovascular Disease

Obesity is a chronic and debilitating disease that has become a global epidemic. Especially severe in the Unites States, obesity currently affects almost 40% of the population. Obesity has a strong causal relationship with numerous serious comorbidities that impair quality of life, shorten life expectancy, and carry a major economic burden. Obesity has particular relevance to cardiologists because it contributes directly to several major cardiovascular diseases and, consequently, increases overall cardiovascular mortality. Multiple treatment options are available, but metabolic and bariatric surgery offers the most effective and durable treatment for obesity. Moreover, metabolic and bariatric operations alleviate and often completely eliminate numerous comorbidities, particularly type 2 diabetes and other cardiovascular risk factors, such as hypertension and dyslipidemia. With their low risk of complications and morbidity, metabolic and bariatric operations significantly improve quality of life and overall survival, particularly reducing death due to cardiovascular disease.

Gastric interventional endoscopy

PURPOSE OF REVIEW

To review new advances in gastric interventional endoscopy.

RECENT FINDINGS

Implementation of gastric endoscopy as a therapeutic option in obesity, gastric cancer, and gastroparesis.

SUMMARY

Less invasive new gastric endoscopic procedures can potentially replace currently offered laparoscopic approaches in many fields. In this article, we will review the use of endoscopic sleeve gastroplasty as a weight loss procedure, endoscopic submucosal dissection in treatment of early gastric cancer, and gastric per-oral endoscopic myotomy in treatment of refractory gastroparesis. These procedures can increase access to bariatric weigh loss procedures, provide an organ-saving curative option for early gastric cancer, and offer a new modality to improve refractory gastroparesis.

Giant perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass

Perforation of a marginal ulcer (MU) is a complication of Roux-en-Y gastric bypass that can be life-threatening. We report a case of a perforated MU that presented 7 months after surgery with several interesting points for discussion. Firstly, the presentation of the ulcer was cryptic with unreliable investigations. Secondly, the ulcer presented again even after anastomotic revision surgery. Finally, the ulcer and the sepsis associated with perforation presented after months of poor nutritional intake with profound hypoalbuminaemia. Perforated MUs causing malnutrition pose clinicians with the difficult decision of which operation to offer; patch repair, revision of the anastomosis or reversal surgery. This case illustrates that primary reversal surgery for a perforated recurrent MU may be the most appropriate surgical management in this clinical situation.

Patient Safety and Quality Improvement Initiatives in Contemporary Metabolic and Bariatric Surgical Practice

Patient safety and quality improvement have been part of bariatric surgery since its inception, and there have been significant improvements in outcomes of bariatric surgery over the past 2 decades. A strong accreditation program exists. This program defines 2 tiers of accredited centers: low-acuity and comprehensive centers similar to the trauma systems. Accreditation has been shown to have a favorable impact on outcomes of bariatric surgery. Bariatric surgery lends itself well to improvements in processes and use of perioperative protocols, such as ulcer and thromboembolic prophylaxis prevention or gallstone prevention and management.

[Stenosis and ulceration after bariatric surgery]

INTRODUCTION

The increasing number of morbidly obese patients leads to a rising number of bariatric procedures in Germany. The operative techniques are highly standardized but such a standardization is lacking for the management of postoperative complications such as stenosis and ulceration after Roux-en-Y gastric bypass (RYGB) surgery and sleeve gastrectomy (SG).

METHODS

The current literature is reviewed and a complication management is developed and presented in this article.

RESULTS AND CONCLUSION

Postoperative stenoses occure with a frequency of 0.1-3.9% after SG and 3-27% after RYGB. Stenosis is secondary to inadequate surgical technique or microinsufficiency. Ulcers can be due to reaction to foreign body, local ischemia, peptic lesion, fistula and microinsufficiency.

CONCLUSION

Endoscopic interventions are successful in most cases for stenosis after RYGB and for short stenoses after SG. After SG long stenoses require redo surgery and conversion to RYGB. Ulcers can be managed by medication with the exception of perforation and hemorrhage, which require emergency laparoscopy.

Risk Factors for Marginal Ulcer After Gastric Bypass Surgery for Obesity: A Population-based Cohort Study

OBJECTIVE

This study aimed to assess risk factors for developing marginal ulcer (MU) after gastric bypass (GBP) surgery for obesity.

BACKGROUND

MU is a common and potentially serious complication of GBP surgery, little is known about its etiology.

METHODS

This population-based cohort study of GBP in 2006-2011 evaluated MU in relation to diabetes, hyperlipidemia, hypertension, chronic obstructive pulmonary disease (COPD), ulcer history, use of proton pump inhibitors (PPIs), aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and selective serotonin reuptake inhibitors (SSRIs). Multivariable Cox proportional hazard regression models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for confounding.

RESULTS

Among 20,294 GBP patients, diabetes and peptic ulcer history entailed statistically significantly increased risk of MU (HR = 1.26, 95% CI 1.03-1.55 and HR  =  2.70, 95% CI 1.81-4.03), although hyperlipidemia, hypertension, and COPD did not. PPI users had an increased HR of MU (HR  =  1.37, 95% CI 1.17-1.60). Aspirin and NSAID consumption less than or equal to median entailed decreased HRs of MU (HR  =  0.56, 95% CI 0.37-0.86 and HR  =  0.30, 95% CI 0.24-0.38), although aspirin and NSAID users more than median had an increased risk and no association with MU, respectively (HR  =  1.90, 95% CI 1.41-2.58 and HR  =  0.90, 95% CI 0.76-1.87). The use of SSRI less than or equal to median had a decreased risk of MU (HR  =  0.50, 95% CI 0.37-0.67), although use more than median entailed increased HR (HR  =  1.26, 95% CI 1.01-1.56).

CONCLUSIONS

Diabetes and peptic ulcer history seem to be risk factors for MU, but not hyperlipidemia, hypertension, or COPD. Limited doses of aspirin, NSAIDs, and SSRIs might not increase the risk, although higher doses of aspirin do. The association with PPI could be due to confounding by indication.

Roux-en-Y gastric bypass reversal: a systematic review

BACKGROUND

Due to the large number of Roux-en-Y gastric bypass surgeries performed over the last decade, reversal of the bypass to normal anatomy has been increasingly reported.

SETTING

University affiliated Teaching Hospital, United States.

OBJECTIVES

The aim of this systematic review was to summarize the literature data regarding the indications, technical considerations, and outcomes of gastric bypass reversal.

METHODS

PubMed/MEDLINE search was conducted for articles reporting reversal of gastric bypass to normal anatomy. Patients' demographic characteristics, primary reason for reversal, reversal technique, and postreversal events were retrieved and categorized from each eligible paper.

RESULTS

Thirty-five articles encompassing a total of 100 patients were eligible. Malnutrition was the most common indication for reversal (12.3%), followed by severe dumping syndrome (9.4%), postprandial hypoglycemia (8.5%), and excessive weight loss (8.5%). Techniques for gastrogastrostomy were available in 42 patients, with the hand-sewn technique as the most common (67.4%) followed by the linear stapler (23.2%) and the end-to-end anastomosis stapler used in 3 patients (6.9%). The reversal technique was performed endoscopically and described in 3 studies (3 patients). Techniques for handling the Roux limb were described in 56 patients (56%); the limb was reconnected in 32 patients (57.2%) and resected in 24 patients (42.8%). Weight regain was the most prevalent postreversal event (28.8%), followed by severe gastroesophageal reflux diseases (10.2%) and persistent abdominal pain (6.8%). There was no reported mortality.

CONCLUSION

Gastric bypass reversal is indicated for excessive weight loss, dumping syndrome, and postprandial hypoglycemia. The procedure is well tolerated and feasible when performed laparoscopically and has no reported mortality.