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Published in:

01-02-2013

Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass

Authors: Mark R. Wendling, John G. Linn, Kara M. Keplinger, Dean J. Mikami, Kyle A. Perry, W. Scott Melvin, Bradley J. Needleman

Published in: Surgical Endoscopy | Issue 2/2013

Abstract

Background

Marginal ulcer formation remains a significant complication of Roux-en-Y gastric bypass (RYGB). Up to 1 % of all RYGB patients will develop free perforation of a marginal ulcer. Classically, this complication has required anastomotic revision; however, this approach is associated with significant morbidity. Several small series have suggested that omental patch repair may be effective. The aim of this study was to examine the management of perforated marginal ulcers following RYGB.

Methods

All patients who underwent operative intervention for perforated ulcers between 2003 and 2011 were reviewed. Those with a history of RYGB with perforation of a marginal ulcer were included in the analysis. Data collected included operative approach, operative time, blood loss, length of hospital stay, complications, smoking history, and steroid or NSAID use.

Results

From January 2003 to December 2011, a total of 1,760 patients underwent RYGB at our institution. Eighteen (0.85 %) developed perforation of a marginal ulcer. Three patients’ original procedure was performed at another institution. Eight patients (44 %) had at least one risk factor for ulcer formation. Treatment included omental patch repair (laparoscopic, n = 7; open, n = 9) or anastomotic revision (n = 2). Compared to anastomotic revision, omental patch repair had shorter OR time (101 ± 57 vs. 138 ± 2 min), decreased estimated blood loss (70 ± 72 vs. 250 ± 71 mL), and shorter total length of stay (5.6 ± 1.4 vs. 11.0 ± 5.7 days).

Conclusions

Perforated marginal ulcer represents a significant complication of RYGB. Patients should be educated to reduce risk factors for perforation, as prolonged proton pump inhibitor therapy may not prevent this complication in a patient with even just one risk factor. In our sample population we found laparoscopic or open omental patch repair to be a safe and effective treatment for this condition and it was associated with decreased operative time, blood loss, and length of stay.

Yang YT, Nichols LM (2011) Obesity and health system reform: private vs. public responsibility. J Law Med Ethics 39:380–386PubMed

Anderson LH, Martinson BC, Crain AL et al (2005) Health care charges associated with physical inactivity, overweight, and obesity. Prev Chronic Dis 2(4):A09PubMed

Buchwald H, Oien DM (2009) Metabolic/bariatric surgery worldwide 2008. Obes Surg 19:1605–1611PubMedCrossRef

Csendes A, Burgos AM, Altuve J et al (2009) Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg 19:135–138PubMedCrossRef

Csendes A, Torres J, Burgos AM (2011) Late marginal ulcers after gastric bypass for morbid obesity. Clinical and endoscopic findings and response to treatment. Obes Surg 21:1319–1322PubMedCrossRef

Dallal RM, Bailey LA (2006) Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis 2(4):455–459PubMedCrossRef

D’Hondt MA, Pottel H, Devriendt D et al (2010) Can a short course of prophylactic low-dose proton pump inhibitor therapy prevent stomal ulceration after laparoscopic Roux-en-Y gastric bypass? Obes Surg 20:595–599PubMedCrossRef

Gumbs AA, Duffy AJ, Bell RL (2006) Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis 2(4):460–463PubMedCrossRef

Higa KD, Boone KB, Ho T (2000) Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients–what have we learned? Obes Surg 10:509–513PubMedCrossRef

10.

Jordan JH, Hocking MP, Rout WR et al (1991) Marginal ulcer following gastric bypass for morbid obesity. Am Surg 57:286–288PubMed

11.

Patel RA, Brolin RE, Gandhi A (2009) Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 5(3):317–322PubMedCrossRef

12.

Rasmussen JJ, Fuller W, Ali MR (2007) Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc 21:1090–1094PubMedCrossRef

13.

Sacks BC, Mattar SG, Qureshi FG et al (2006) Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2(1):11–16PubMedCrossRef

14.

Wilson JA, Romagnuolo J, Byrne TK et al (2006) Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol 101:2194–2199PubMedCrossRef

15.

MacLean LD, Rhode BM, Nohr C et al (1997) Stomal ulcer after gastric bypass. J Am Coll Surg 185(1):1–7PubMedCrossRef

16.

Azagury DE, Abu Dayyeh BK, Greenwalt IT et al (2011) Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy 43:950–954PubMedCrossRef

17.

Capella JF, Capella RF (1999) Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 9:22–27 discussion 28PubMedCrossRef

18.

Papasavas PK, Gagne DJ, Donnelly PE et al (2008) Prevalence of Helicobacter pylori infection and value of preoperative testing and treatment in patients undergoing laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 4:383–388PubMedCrossRef

19.

Scheffel O, Daskalakis M, Weiner RA (2011) Two important criteria for reducing the risk of postoperative ulcers at the gastrojejunostomy site after gastric bypass: patient compliance and type of gastric bypass. Obes Facts 4(Suppl 1):39–41PubMed

20.

Lublin M, McCoy M, Waldrep DJ (2006) Perforating marginal ulcers after laparoscopic gastric bypass. Surg Endosc 20:51–54PubMedCrossRef

21.

Felix EL, Kettelle J, Mobley E et al (2008) Perforated marginal ulcers after laparoscopic gastric bypass. Surg Endosc 22:2128–2132PubMedCrossRef

22.

Kalaiselvan R, Exarchos G, Hamza N et al (2011) Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management. Surg Obes Relat Dis. doi:10.1016/j.soard.2011.06.008

23.

Wheeler AA, de la Torre RA, Fearing NM (2011) Laparoscopic repair of perforated marginal ulcer following Roux-en-Y gastric bypass: a case series. J Laparoendosc Adv Surg Tech A 21:57–60PubMedCrossRef

24.

Sasse KC, Ganser J, Kozar M et al (2008) Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn? Obes Surg 18:530–534PubMedCrossRef

25.

Printen KJ, Scott D, Mason EE (1980) Stomal ulcers after gastric bypass. Arch Surg 115:525–527PubMedCrossRef

26.

Sapala JA, Wood MH, Sapala MA et al (1998) Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 8:505–516PubMedCrossRef

27.

Escalona A, Devaud N, Perez G et al (2007) Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study. Surg Obes Relat Dis 3:423–427PubMedCrossRef

28.

Bendewald FP, Choi JN, Blythe LS, Selzer DJ, Ditslear JH, Mattar SG (2011) Comparison of hand-sewn, linear-stapled, and circular-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg 21(11):1671–1675PubMedCrossRef

29.

Schirmer B, Erenoglu C, Miller A (2002) Flexible endoscopy in the management of patients undergoing Roux-en-Y gastric bypass. Obes Surg 12:634–638PubMedCrossRef

30.

Yang CS, Lee WJ, Wang HH et al (2006) The influence of Helicobacter pylori infection on the development of gastric ulcer in symptomatic patients after bariatric surgery. Obes Surg 16:735–739PubMedCrossRef

31.

Hartin CW Jr, ReMine DS, Lucktong TA (2009) Preoperative bariatric screening and treatment of Helicobacter pylori. Surg Endosc 23:2531–2534PubMedCrossRef

32.

Steinemann DC, Schiesser M, Clavien PA et al (2011) Laparoscopic gastric pouch and remnant resection: a novel approach to refractory anastomotic ulcers after Roux-en-Y gastric bypass: case report. BMC Surg 11:33PubMedCrossRef

33.

Racu C, Dutson EP, Mehran A (2010) Laparoscopic gastrojejunostomy revision: a novel approach to intractable marginal ulcer management. Surg Obes Relat Dis 6(5):557–558PubMedCrossRef

34.

Binenbaum SJ, Dressner RM, Borao FJ (2007) Laparoscopic repair of a free perforation of a marginal ulcer after Roux-en-Y gastric bypass: a safe alternative to open exploration. JSLS 11:383–388PubMed

35.

Bramkamp M, Muller MK, Wildi S et al (2006) Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Obes Surg 16:1545–1547PubMedCrossRef

36.

Chin EH, Hazzan D, Sarpel U et al (2007) Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Surg Endosc 21:2110PubMedCrossRef

37.

St. Jean MR, Dunkle-Blatter SE, Petrick AT (2006) Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2(6):668PubMedCrossRef

38.

Siu WT, Leong HT, Law BK et al (2002) Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 235:313–319PubMedCrossRef

39.

Minutolo V, Gagliano G, Rinzivillo C et al (2009) Laparoscopic surgical treatment of perforated duodenal ulcer. Chir Ital 61:309–313PubMed

40.

Lunevicius R, Morkevicius M (2005) Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer. World J Surg 29:1299–1310PubMedCrossRef

41.

Bertleff MJ, Lange JF (2010) Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 24:1231–1239PubMedCrossRef

Title: Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass
Authors: Mark R. Wendling
John G. Linn
Kara M. Keplinger
Dean J. Mikami
Kyle A. Perry
W. Scott Melvin
Bradley J. Needleman
Publication date: 01-02-2013
Publisher: Springer-Verlag
Published in: Surgical Endoscopy / Issue 2/2013
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-012-2492-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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