Chronic Marginal Ulcers After Gastric Bypass
Chronic Marginal Ulcers After Gastric Bypass
The purpose of this study is to determine the feasibility, safety, and efficacy of revision
 gastroplasty along with other adjunct procedures in the treatment of intractable / chronic
 marginal ulcers after Roux-en-Y gastric bypass. A secondary aim is the identification of good
 and poor outcome predictors after revisional strategies for intractable or chronic marginal
 ulcer.
The epidemic of overweight and obesity in the United States of America along with its
 comorbidities continues to expand. Bariatric surgery has demonstrated to be the most
 effective and sustained method to control severe obesity and its comorbidities. For instance,
 type 2 diabetes mellitus was completely resolved in 76.8%, systemic arterial hypertension was
 resolved in 61.7%, dyslipidemia improved in 70% and obstructive sleep apnea-hypopnea syndrome
 was resolved in 85.7%. Furthermore, bariatric surgery significantly increases life expectancy
 (89%) and decreases overall mortality (30-40%), particularly deaths from diabetes, heart
 disease, and cancer. Lastly, preliminary evidence about downstream savings associated with
 bariatric surgery offset the initial costs in 2 to 4 years.

 Since 1998, there has been a substantially progressive increase in bariatric surgery. In
 2005, the ASMBS reported that 81% of bariatric procedures were approached laparoscopically
 and in 2007, 205,000 people had bariatric surgery in the United States from which
 approximately 80% of these were Gastric Bypass. Moreover, there is a mismatch between
 eligibility and receipt of bariatric surgery with just less than 1% of the eligible
 population being treated for morbid obesity through bariatric surgery. Along with the
 increasing number of elective primary weight loss procedures, up to 20% of post RYGB patients
 cannot sustain their weight loss beyond 2 to 3 years after the primary bariatric procedure.
 Thus, revisional surgery for poor weight loss and re-operations for technical or mechanical
 complications will rise in a parallel manner.

 A common late complication after gastric bypass surgery is marginal ulceration, an ulcer at
 the margins of the gastrojejunostomy on the jejunal side. Its incidence after RYGB ranges
 from as low as 0.6 to as high as 16%. After 1,040 laparoscopic RYGB surgeries, the incidence
 rate, in our hands, is 1.4% and mainly related to NSAID´s use. In observational cohort
 studies, the presence of specific technical factors - staple-line dehiscence or
 gastro-gastric fistula, enlarged pouch, foreign material and local ischemia - and
 environmental factors - tobacco, NSAID´s, alcohol consumption, and H pylori infection among
 others - have been associated with marginal ulceration however the exact etiopathogenesis has
 not been completely elucidated.

 Similar to peptic ulcer disease (PUD), most marginal ulcers respond to medical therapy,
 specifically sucralfate and acid-lowering medication. In contrast, when perforation,
 obstruction, penetration, bleeding and/or intractability presents, complex or complicated
 ulcer disease, warrants surgical intervention.

 The intestinal mucosa is not typically exposed to gastric acid, which is neutralized by the
 alkaline biliopancreatic secretions. The jejunal mucosa has no natural barriers; when exposed
 to gastric acid, it ulcerates easily. Capella & Capella demonstrated that transecting the
 gastric segments significantly reduce staple-line dehiscence; this is the so-called divided
 gastric bypass. In the retrospective analysis of their consecutive series, the incidence for
 gastro-gastric fistula (GGF) formation after undivided gastric bypass (GBP) was 23%, after a
 partially divided GBP was 19%, after a completely divided GBP was 2% and after complete
 transection with interposition of the jejunal limb was 0% (p <0.001). MacLean et al confirmed
 that divided primary gastric bypass decreases GGF formation (29% vs. 3%). Also, patients who
 developed marginal ulcers had a lower pH as well as a greater time with a pH less than 2
 correlating 100% with the presence of GGF; closure of the GGF increased the pH in the pouch
 with subsequent healing of the marginal ulcer.

 An unusually large gastric pouch (such as horizontal pouches, retained fundus, long lesser
 curvature based pouches or enlarged after initially being sized adequately) contain more
 acid-producing parietal cells. Increased acid production in the pouch carries the risk of
 developing marginal ulcers. Acid secretion in the small pouch after RYGB is virtually absent.
 Smith et al measured basal and pentagastrin-stimulated gastric acid secretion from the pouch
 were significantly lower compared to age and sex-matched controls. Likewise, MacLean et al
 reported a significantly lower pH & greater time with pH <2 in the gastric pouches of
 marginal ulcers and/or GGF patients after RYGB compared to non-complicated RYGB controls.
 Thus, creating a esophagojejunostomy would solve the gastric acid factor for developing
 marginal ulcers however the high incidence of anastomotic failure and unknown weight loss
 results are prohibitive for this approach. Sapala et al created a micro-pouch or
 cardiojejunostomy to decrease at maximum the parietal cell mass with a low incidence of
 marginal ulcers (0.01% at 1 years of follow-up) as well as to limit the pouch dilation. By
 Histopathology with a semi-quantitative approach, Gustavsson et al reported less
 acid-producing parietal cells within smaller pouches. With his next study (n=12), Gustavsson
 et al, demonstrated a significantly higher time exposure to a pH<4 in patients with marginal
 ulcer after RYGB (4x3cm pouch) compared to controls (p< 0.01). Furthermore, after downsizing
 the pouch, repeated pH-metry showed the % of time with pH <4 declined from 100% prior to 6%
 after revisionary surgery.

 The anastomotic techniques influence the incidence of marginal ulcers. Capella & Capella
 reported a consecutive series with significant decrement from 5.1% to 1.5% (p< 0.001) after
 switching from a stapled to a hand-sewn anastomosis. Likewise, after changing from an inner
 layer of absorbable suture and an outer layer of nonabsorbable material to a double-layer of
 absorbable suture the incidence rate improved from 1.6% to 0%. Dr Schauer´s group confirmed a
 significant improvement in the incidence rate of MU from a 2.6% with the use of nonabsorbable
 suture for the outer layer to 1.3% after the change to absorbable suture for both layers (p <
 0.001).

 Local ischemia, in the immediate postoperative period, is probably secondary to technical
 reasons. Fundamental aspects for decreasing tension and local ischemia at the
 gastrojejunostomy are dissection of the tissues around the pouch without devascularizing the
 lesser curvature and complete mobilization of a well-perfused Roux limb.

 In epidemiological, clinical and experimental studies, NSAID´s have been identified as one of
 the three major risk factors for PUD. Wilson et al found NSAID´s consumption to significantly
 increase the risk for marginal ulcer following RYGB (adjusted OR 11.5, 95%CI 4.8-28).

 In epidemiological, clinical and experimental studies, Tobacco is another major risk factor
 for PUD. Smoking carries an overall relative risk of 2.2 (95%CI, 2.0-2.3).

 Helicobacter pylori (H pylori) infection carries an overall relative risk of 3.3 (95%CI,
 2.6-4.4) for developing PUD. A synergistic relationship exists between H pylori infection and
 NSAID´s consumption for developing PUD with an overall risk of 3.5 (95%CI, 1.26-9.96)
 compared to either H pylori or NSAID´s negative individuals. In Papasavas et al study,
 preoperative H. pylori testing with prophylactic eradication did not decrease the incidence
 of MU or erosive pouch gastritis.

 The pathophysiological mechanisms of damage to the gastric mucosa of ethanol and alcoholic
 beverages are poorly understood. There are no studies available about the effect of alcohol
 on marginal ulcer development after RYGB.

 Cocaine use is responsible for approximately 143,000 Emergency Department visits annually;
 19% of American, between 18 to 25 years old, have used cocaine: more than 1% of the Americans
 use cocaine at least once a week; and approximately 50% of all drug-related deaths were
 secondary to Cocaine. The temporal association between smoking cocaine (crack) and GI tract
 manifestations include ulceration, perforation, visceral infarction, and retroperitoneal
 fibrosis.

 Re-operative strategies for addressing chronic marginal ulcers after gastric bypass have been
 scarcely described and mostly are reports of a case or small series of cases. The revisional
 strategies described are I) ulcer excision with revision of the gastrojejunostomy and gastric
 transection if needed, II) ulcer excision with pouch downsizing and redo of
 gastrojejunostomy, III) ulcer excision with resection of the ischemic Roux limb segment, and
 IV) ulcer excision and reversal. The possible adjuvant procedures includes I) proximal
 remnant gastrectomy (partial gastrectomy), and II) vagotomy.

 In summary, there is scant information about late complications after gastric bypass
 especially after the widespread adoption of the laparoscopic approach and the modern
 anatomical construct of Roux-en-Y Gastric Bypass surgery.
Inclusion Criteria:

 -  Chronic/Intractable, either recurrent or persistent, marginal ulcers after Roux-en-Y
 gastric bypass surgery for clinically severe obesity

 Exclusion Criteria:

 -  Chronic or Intractable marginal ulcer after other bariatric procedures

 -  Revision or re-operation by open approach

 -  missing records and/or unreachable patients with scant information for analysis