Refractory RYGB ulcers are troublesome for both the patient and the bariatric surgeon. Dr. Adrian Marius Nedelcu presents a case representing this complication and how it was managed. An expert commentary by Dr. Dino Spaniolas and his colleague Dr. Andrew Brown on the management of ulcers after gastric bypass is attached.
Case (Dr. Nedelcu)
The patient is a 30 years old female who underwent Laparoscopic Sleeve Gastrectomy (LSG) in 2012 for a weight of 116 kg (BMI 43). She has an excellent result for weight loss after 2 years (weight 63 kg, BMI 23). Three years after the patient presented important reflux symptoms partially improved by PPI. At five years after the initial surgery, the patient presented with weight regain associated with persistent, invalidating reflux (weight 85 kg, BMI 32). Her weight regain can be related also to the reflux disease as she is describing to alleviate symptoms. The decision to convert the LSG into one anastomosis gastric bypass was taken in 2017. The recorded procedure showed us a long gastric pouch, as the sectioning of the stomach was performed lower than the incisura angularis. Despite this, few months after the revision she started to have a biliary reflux associated also with epigastric pain. The upper endoscopy showed important amount of bile in the gastric pouch and a small perianastomotic ulcer. An initial medical treatment was attempted, but the endoscopic control (6 months later) showed the persistence with increasing in diameter of the perianastomotic ulcer. In 2018, the patient was reoperated with resection of the gastrojejunal anastomosis and revision to RYGBP with good outcome.
After an initial asymptomatic period, at 6 months follow up visit she is starting again to describe excruciating epigastric pain. The endoscopy showed us an important ulcer which was treated initial by medical treatment (maximum dose of PPI). During this period the patient had 2 negatives nicotine urine tests and no use of AINS was identified. An abdominal CT and MRI were negative for any type of tumor and the gastrin level was normal. The endoscopic control (3 months after) showed an important perianastomotic ulcer (Figure 1).
Different surgical options were discussed. The total gastrectomy with eso-jejunal anastomosis is representing the radical option. The patient was not very enthusiastic about this option. The reversal to the “normal” anatomy (as the patient had already had a sleeve) was not a real option as the symptoms of reflux following sleeve were really invalidated. To perform isolated truncal vagatomy is representing an option with insufficient results in the literature.
In conclusion we decided with patient to perform a pouch revision with almost complete gastrectomy (including antrum resection) with complete manual anastomosis. The hospital stay was 2 days with uneventful postoperative recovery. The postoperative control at one month was normal.
Expert Commentary (Dr. Spanioloas and Dr. Brown)
Management of Gastrojejunal Anastomotic Ulcers following Roux-en-Y Gastric Bypass
Background
With over forty thousand Roux-en-Y gastric bypasses (RYGB) performed for obesity in the United States in 2016, marginal ulceration has become prevalent, and important complication.1 Marginal ulcers are those ulcers that develop at the gastrojejunal anastomosis following RYGB. The reported incidence ranges from 0.6% to 16%.2,3 However, recent data from a large statewide database yielded a marginal ulcer rate of 11.4%, with 0.6% of all RYGB patients eventually undergoing surgical therapy for their ulcer. Give this high ulcer rate, identification of risk factors and early intervention can mitigate further complications.4 Established risk factors include non-steroids anti-inflammatory drugs, corticosteroid use, nicotine use, foreign body reactions to staples or suture material, and Helicobacter pylori infection.2,5 Notably, the estimated 8 year rate of marginal ulceration in patients with tobacco use was 17.8%.6 Patients with marginal ulcers may present with acute or chronic abdominal pain, or more serious complications including perforation, bleeding, or obstruction at the anastomosis. Diagnosis of a marginal ulcer is readily established by upper endoscopy.
Management
Medical
Treatment begins with risk factor modification, and medical therapy. Due to the hypothesis that acidity in the gastric pouch plays a role in the pathophysiology of ulcer formation, proton pump inhibitors (PPI) are the mainstay of treatment. Unfortunately, the size of the gastric pouch, and rapid small bowel transit time of a RYGB patient limit the effectiveness of PPI capsules. Recently, delivery of PPI via an open capsule approach was studied against intact capsule PPI, showing significantly decreased ulcer healing times with the open capsule approach.7 Adding open capsule PPI therapy to sucralfate and misoprostol form a strong backbone of primary therapy for marginal ulceration.
Surgical
For patients who present with perforation, surgical therapy is focused on addressing the perforation itself, followed by medical therapy, risk factor optimization (smoking cessation, discontinuation of NSAIDs, H. Pylori eradication, etc) and endoscopic surveillance. Endoscopic surveillance is important given the high rate of recurrence following surgical treatment.4 Patients with marginal ulcers and failure of medical therapy are also considered for surgical management. This usually involves resection of the gastrojejunostomy including the ulcer, and redo of the anastomosis. In these cases, our preference is to use a fully handsawn approach with absorbable sutures in most cases. In patients with a very large pouch, the resection of the gastrojejunostomy is such to allow for resizing of the pouch down to a small size. If a patient cannot quit smoking in the face of a persistent marginal ulcer or patients with other significant RYGB complications (e.g. hypoglycemia), reversal of the bypass with or without truncal vagotomy may be necessary. If the pouch is already small, the only option may be resection of the entire pouch and esophagojejunostomy. Patients with present with significant weight loss and a near obstructing ulcer that leads to per os intolerance, can be managed with supplemental feeding (often with remnant gastrostomy) and serial endoscopic dilations. Adjuncts for dilations can include steroid injections or even endoscopic stenting. If the endoscopic therapies are not successful, the enteral nutrition would allow for optimization prior to surgical revision.
Surveillance
Surveillance of marginal ulcers should be employed to document successful healing, or to diagnose recalcitrant ulcers. Upper endoscopy should be performed 8-12 weeks after treatment initiation to evaluate the ulcer bed. Ulcers can often be completely healed and eradicated even following repair of a perforated ulcer alone.
Recurrent Ulcers
Management of recurrent marginal ulceration following previous repair, again begins with risk factor modification including nicotine cessation, Helicobacter pylori eradication, and cessation of NSAID use. Patients may also be evaluated for other causes of ulceration, such as the presence of Zollinger-Ellison syndrome. When risk factors are optimized and the ulcer persists, re-revision of the gastrojejunostomy may be an option. This often requires resection of the pouch and esophagojejunostomy. Alternatives include thoracoscopic truncal vagotomy or endoscopic coverage of the ulcer bed. Thoracoscopic truncal vagotomy has been shown to be an acceptable alternative approach to anastomotic revision with equivalent short term results, although the literature is unclear on the effectiveness over anastomotic revision.9 Finally, endoscopic coverage of the ulcer bed by either endoscopic suturing, stent deployment, or both, has been used in small series with high resolution of ulcers on surveillance EGD.10 This could be a valid option for high risk patients, ones with recurrence after previous revision or in select patients who would otherwise require an esophagojejunostomy.
Summary Management of marginal ulcers begins with endoscopic diagnosis, risk factor modification, and medical therapy centered around open capsule PPI. Perforated ulcers are managed in the operating room with repair of the perforation or revision of the anastomosis. Surveillance endoscopy is done at 8 to 12 weeks. Recurrent and recalcitrant ulcers can be managed operatively, or with newer techniques including endoscopic coverage of the ulcer bed, and thoracoscopic truncal vagotomy. The latter two approaches are often reserved for selected high risk patients or ones with recurrence after GJ revision.
Key Points
Open capsule PPIs and elimination of risk factors are the key steps for ulcer resolution. After failure of medical therapy, revision of the gastrojejunostomy should be considered. Patients with persistent ulcers and inability for smoking cessation in need of revision may be better treated with reversal of the gastric bypass. Such decision should be individualized. For high risk patients and when surgical resection would lead to an esophageal anastomosis, consideration should be given to endoscopic alternatives or truncal vagotomy.
References
1. Surgery American Society for Metabolic and Bariatric Surgery (2016) Estimate of bariatric surgery numbers. 2011-2016.
2. Sapala JA, Wood MH, Sapala MA, Flake TM Jr (1998) Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 8:505-516.
3. MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP (1997) Stomal ulcer after gastric bypass. J Am Coll Surg 185:1-7.
4. Pyke O, Yang J, Cohn T, Yin D, Docimo S, Talamini MA, Bates AT, Pryor AD, Spaniolas K (2019) Marginal ulcer continues to be a major source of morbidity over time following gastric bypass. Surg Endosc 33:3451-3456.
5. 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 21:1671-1675.
6. Spaniolas K, Yang J, Crowley S, Yin D, Docimo S, Bates AT, Pryor AD (2018) Association of Long-term Anastomotic Ulceration After Roux-en-Y Gastric Bypass With Tobacco Smoking JAMA Surg 153(9):862-863.
7. Schulman AR, Chan WW, Devery A, Ryan MB, Thompson CC (2017) Open Proton Pump Inhibitor Capsules Reduce Time to Healing Compared With Intact Capsules for Marginal Ulceration Following Roux-en-Y Gastric Bypass. Clin Gastroenterol H 15:494-500.
8. Altieri MS, Pryor AD, Yang J, Yin D, Docimo S, Bates AT, Talamini MA, Spaniolas K (2018) The natural history of perforated marginal ulcers after gastric bypass surgery. Surg Endosc 32:1215-1222.
9. Bonanno A, Tieu B, Dewey E, Husain F (2019) Thoracoscopic truncal vagotomy versus surgical revision of the gastrojejunal anastomosis for recalcitrant marginal ulcers. Surg Endosc 33:607-611.
10. Barola S, Fayad L, Hill C, Magnuson T, Schweitzer M, Singh V, Chen Y, Ngamruengphong S, Khashab MA, Kalloo AN, Kumbhari V (2018) Endoscopic Management of Recalcitrant Marginal Ulcers by Covering the Ulcer Bed. Obes Surg 28:2252-2260.
