Response to Letter to the Editor: An Evidence Based Algorithm for the Management of Marginal Ulcers following Roux-en-Y Gastric Bypass

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We would like to thank Dr Mrak for the opportunity to comment on his interesting point that pH meter should be included within the algorithm for the management of marginal ulcers. We agree the Siilin paper contributes to the argument that hyperacidity in the pouch is one of the risk factors for marginal ulceration and that a smaller pouch size results in less acid release and has the potential to reduce marginal ulcer rates [1]. Nevertheless, in the absence of any detectable marginal ulceration, we are unaware of any evidence supporting lifelong acid suppression, although this was not covered in the algorithm, which focused on patients with a diagnosis of marginal ulceration. It would, however, seem reasonable to offer a trail of proton pump inhibitor (PPI) treatment to symptomatic patients, which could be continued if beneficial. We remain unconvinced that measuring pH levels is likely to alter the management in these patients. …