Endoscopic Therapy for Bleeding Marginal Ulcers After Gastric Bypass
Endoscopic Therapy for Bleeding Marginal Ulcers After Gastric Bypass
The objective of this study is to identify the incidence rate; describe the risk factors,
 clinical presentation, and endoscopic treatment; assess the morbidity, mortality, and overall
 performance of the management of patients with actively bleeding marginal ulcers after
 Roux-en-Y gastric bypass (RYGB) surgery.
Marginal ulceration "MU", which presents as an ulcer at the margins of the gastrojejunostomy
 on the jejunal side, is a common late complication after RYGB. Its incidence after RYGB
 ranges from as low as 0.6 to as high as 16%. In our hands with the laparoscopic hand-sewn
 technique for the GJ, the incidence is 1.4%. 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, complicated marginal
 ulcers - perforation, bleeding, or chronicity (obstruction, penetration, and intractability)-
 warrants operative intervention.

 Early presentation of hemorrhage after RYGB is mostly related to staple-line failure and may
 result in either GI or intraabdominal hemorrhage. When indicated, operative interventions
 consist of either endoscopic therapy, re-operation, or both. In contrast, late presentation
 of gastrointestinal hemorrhage after RYGB is mostly secondary to a bleeding marginal ulcer
 however complicated peptic ulcer disease can present in the excluded stomach and duodenum as
 well.

 Most literature available for the management of GI hemorrhage after RYGB is for the early
 presentation of hemorrhage secondary to staple-line failure. Hence, options for endoscopic
 hemostatic therapy described in this scenario are I) injection therapy, II) coagulation
 therapy, III) endoscopic clipping, and IV) a combined modality (for example injection &
 coagulation or injection and clipping).

 The feasibility, reliability, reproducibility, efficacy, validity and safety of the
 endoscopic hemostatic therapy for acutely bleeding peptic ulcers has been well documented.
 Multiple risk-stratification tools for upper-GI hemorrhage have also been developed such as
 the Blatchford, clinical and complete Rockall scores, and the Forrest classification.
 Moreover, pre and post endoscopic schemes of PPI´s therapy in patients with bleeding peptic
 ulcers is effective and cost-saving. However, All of them have not been validated in the
 obese population status post RYGB complicated with a bleeding marginal ulcer.

 Summarizing, there is scant information about the management of 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. We formally analyze the
 management efficacy of patients with actively bleeding marginal ulcers after Roux-en-Y
 gastric bypass (RYGB) surgery.
Inclusion Criteria:

 -  patients status post laparoscopic RYGB surgery with active gastrointestinal hemorrhage
 secondary to marginal ulcer

 Exclusion Criteria:

 -  bleeding marginal ulcers after other bariatric procedures

 -  staple-line bleeding after RYGB

 -  iron-deficiency anemia (chronic) secondary to non-actively bleeding marginal ulcer
 after RYGB

 -  other sources of GI bleeding different from marginal ulcer such as from staple-lines,
 complicated PUD, and other surgical and medical causes of GI hemorrhage

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