Marginal Ulcer Research Articles

2129 Lumen-Apposing Metal Stent for Benign Gastric Outlet Obstruction!

INTRODUCTION: Lumen-apposing metal stent (LAMS) placement via endoscopic ultrasound (EUS)-guided gastroenterostomy has recently emerged as a promising technique for the management of malignant gastric outlet obstruction (GOO). This is safe, effective and technically feasible if performed by trained advanced endoscopists. Despite that LAMS use in malignant GOO is well defined, it is rarely performed for benign etiologies of GOO and only 4 cases have been reported in the literature. We report the case of a patient with GOO secondary to benign duodenal stricture that was successfully managed by LAMS placement. CASE DESCRIPTION/METHODS: A 60-year-old man with history of recurrent duodenal ulcers presented for vomiting and food intolerance for few days. Two years ago he had a GOO secondary to his ulcer disease and was managed by surgical gastrojejunostomy (GJ). A subsequent marginal ulcer perforation required resection of the GJ with small bowel anastomosis and insertion of a GJ tube. Upon presentation, physical examination was notable for epigastric tenderness with no rebound or rigidity. Contrast computed tomography (CT) scan of the abdomen showed a markedly distended stomach and proximal duodenum with focal narrowing near the pancreatic head (Figure 1). Enteric contrast reached the rectum indicating the absence of complete obstruction. Upper endoscopy showed retained solid material in stomach and an almost completely occluded “pin hole” duodenal lumen that could not be traversed with the endoscope. A wire-guided through the scope dilation with a balloon was performed in conjunction with fluoroscopy but was unsuccessful (Figure 2) so a 10 mm × 15 mm EUS-guided LAMS was successfully deployed. Patient’s symptoms resolved and he was able to tolerate diet. DISCUSSION: GOO usually occurs secondary to malignancy-related mass effect or luminal invasion. Less commonly GOO can be attributed to benign etiologies namely ulcers, caustic ingestion and inflammation. Often managed by endoscopic balloon dilation, benign strictures can recur. Other less favored options include self-expandable metal stents which use is limited by a high rate of migration and failure and surgical approach which provides definitive treatment but is associated with a high risk of mortality and morbidity. LAMS is a novel and appealing less invasive approach proven to be a safe alternative allowing early restoration of enteral luminal access with good short term success and satisfying safety profile. Further studies and long term follow up are recommended.

A122 Laparoscopic Truncal Vagotomy combined with Surgical Resection for Perforated or Recalcitrant Marginal Ulcers

A122 Laparoscopic Truncal Vagotomy combined with Surgical Resection for Perforated or Recalcitrant Marginal Ulcers

A252 Robotic Revision of Chronic Marginal Ulcer and Bilateral Truncal Vagotomy Following a Roux en Y Gastric Bypass

A252 Robotic Revision of Chronic Marginal Ulcer and Bilateral Truncal Vagotomy Following a Roux en Y Gastric Bypass

A234 Laparoscopic Reversal of a Gastric Bypass for Shortgut from a missed Internal hernia

The patient had a Roux en Y gastric bypass two years ago and had presented to an outside hospital for increasing abdominal pain. The patient was evaluated in the ER and was evaluated with a CT scan which was read as normal with no obstruction. General Surgery was consulted and felt patient would be appropriate for a medical floor bed. Patient was admitted to the medicine service with presumed diagnosis of marginal ulcer, placed on PPI and pain medications and GI medicine consult was obtained. Gastroenterology agreed with PPI's and schdeuled pt for outpatient endoscopy after discharge. Over the weekend patient's pain medications were escalated and on Monday morning patient begged his attending physician and stated " this amount of pain cannot be normal". The attending physician arranged for an inpatient endoscopy, Endoscopy revealed a necrotic roux limb. The patient was then transferred emergently to a nearby hospital that had a Bariatric Surgeon who emergently explored the patient and found necrotic bowel from an internal hernia with volvulus and resected bowel and refashioned the gj and recreated a jejunojejunostomy. Patient was left with 200 cm of total small bowel length with a 50 cm roux limb. Over the next several months patient had tremendous diarrhea and was treated with antidiarrheal agents, gatex and enteral supplementation. When pt was referred to us his albumin was 1.2 with anasarca. for 3 months he was given TPN and when his albumin was 2.8 we took him for a reversal.

Minimally invasive Roux-en-Y reconstruction as a salvage operation after failed nissen fundoplication.

Conversion of Nissen fundoplication to Roux-en-Y (RnY) anatomy may be indicated in patients with post-surgical complications or who fail to achieve durable control of their disease. Herein we describe the largest series of patients at a single institution who underwent minimally invasive conversion of Nissen fundoplication to RnY reconstruction. All patients with prior Nissen fundoplication which were converted to RnY anatomy at our institution from March 2009 through November 2017 were retrospectively reviewed and analyzed. Patients were identified based on CPT codes and the description of the operation performed. All cases with attempted minimally invasive approach were included for analysis. Fifty patients underwent conversion from prior Nissen fundoplication to RnY anatomy during the study period. The cohort was 84.0% female with a mean age of 53.5years and a median body mass index of 36.7kg/m2. Thirteen patients (26.0%) had multiple prior foregut operations. Complications from fundoplication that warranted revision included recurrent hiatal hernia (n = 16), post-surgical gastroparesis (n = 10), and mechanical complications from the wrap (n = 8). An additional fourteen patients underwent conversion to RnY for metabolic disease. The mean operative time and estimated blood loss were 266min and 132mL, respectively, with all but one (98.0%) completed with a minimally invasive approach. The median length of stay was 5days. Complications included marginal ulcer (n = 2), superficial surgical site infection (n = 2), anastomotic leak (n = 2), and one case each of pulmonary embolism, small bowel obstruction, and gastrointestinal bleeding. There were no mortalities at a median follow-up of 12.4months. Conversion of prior Nissen fundoplication to RnY anatomy is technically challenging, although it is safe and feasible even in the setting of multiple prior foregut operations. A minimally invasive approach should be offered to patients by surgeons with experience in revisional foregut and bariatric surgery.

Scleritis and anterior uveitis may herald the development of an epibulbar tumor in patients with extranodal Rosai-Dorfman disease: a case report

BackgroundRosai-Dorfman disease is a rare non–Langerhans cell histiocytosis. Ocular involvement is even rarer, mostly involving the orbit and eyelids, although marginal corneal ulcers, uveitis, and epibulbar masses have also been reported, and is characterized by multiple recurrences. However, the disease course and optimal treatment strategies remain undetermined, in light of the rarity of this disease.Case presentationWe reported a 36-year-old male patient with the extranodal form of Rosai-Dorfman disease, presenting with scleritis and anterior uveitis in the left eye, who experienced subsequent development of an epibulbar tumor in the same eye. The patient was also complicated by a relapsing facial nodule on the right cheek. After the pathological diagnosis of Rosai-Dorfman disease was obtained, the patient underwent surgical excision of the epibulbar tumor and the facial nodule, accompanied by systemic immunosuppression therapy. At the last follow-up, the patient was asymptomatic without signs of recurrence.ConclusionsThis report highlights the progression of ocular manifestations of Rosai-Dorfman disease and emphasizes the importance of systemic therapy.

Crohn's Disease of the Esophagus, Duodenum, and Stomach.

Upper gastrointestinal Crohn's is an under-reported, under-recognized phenotype of Crohn's disease. Routine screening in the pediatric population has shown a higher prevalence compared with adults; however, most adult patients remain asymptomatic with respect to upper gastrointestinal Crohn's disease. For the patients who are symptomatic, medical treatment is the first line of management, except for cases of obstruction, perforation, or bleeding. Though most patients respond to medical therapy, mainly steroids, with the addition of immunomodulators and more recently biologics agents, surgical intervention is usually required only for obstructing gastroduodenal disease secondary to strictures. Strictureplasty and bypass are safe operations with comparable morbidity, although bypass has higher rates of dumping syndrome and marginal ulceration in the long term. Rare cases of gastroduodenal fistulous disease from active distal disease may involve the stomach or duodenum, and esophageal Crohn's disease can fistulize to surrounding structures in the mediastinum which may require the highly morbid esophagectomy.

One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass for Morbid Obesity: an Updated Meta-Analysis.

We aim to review the available literature on morbidly obese patients treated with one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) in order to compare the clinical outcomes of the two methods. A literature search was performed in PubMed, Cochrane Library, and Scopus, in accordance with the PRISMA guidelines. Sixteen studies were included in the qualitative analysis, and 11 studies were included in the quantitative analysis (meta-analysis), incorporating 12,445 patients. OAGB was associated with shorter mean operative time. The length of hospital stay was comparable between the two procedures. The incidence of leaks, marginal ulcer, dumping, bowel obstruction, revisions, and mortality was similar between the two approaches. The incidence of malnutrition was increased in patients treated with OAGB, while the incidence of internal hernia and bowel obstruction was greater in the RYGB group. In addition, the OAGB was associated with greater % excess weight loss (%EWL) at 1, 2, and 5years postoperatively. The rate of diabetes remission was greater in the OAGB group. Nonetheless, the rate of hypertension and dyslipidemia remission was similar between OAGB and RYGB. The present meta-analysis is the best currently available evidence on the topic and demonstrates the superiority of OAGB compared with RYGB, in terms of weight loss and diabetes remission. However, the OAGB was associated with a significantly higher incidence of malnutrition, thus indicating the significant malabsorptive traits of this operation.

Total laparoscopic distal gastrectomy for gastric cancer: uncut Roux-en-Y anastomosis versus Billroth II anastomosis

Objective To compare the advantages and disadvantages between Uncut Roux-en-Y anastomosis and Billroth Ⅱ anastomosis in total laparoscopic distal gastrectomy (TLDG) for gastric cancer. Methods The clinical data of 132 patients with distal gastric cancer, who underwent TLDG with Uncut Roux-en-Y anastomosis or Billroth Ⅱ anastomosis in the Affiliated Hospital, Medical School of Ningbo University from February 2015 to December 2017, were retrospectively analyzed. There were 52 patients receiving TLDG with uncut Roux-en-Y anastomosis (RA group) and 80 patients receiving TLDG with Billroth Ⅱ anastomosis (BA group). Results Compared with BA group,the RA group had a longer operation time [(240.6±49.6) min vs. (202.2±36.4) min, F=2.356, P=0.000]and anastomosis time[(49.1±5.9) min vs. (47.3±4.2) min, F=4.45, P=0.043], more intraoperative blood loss[(128.9±130.0)ml vs. (79.2±62.5) ml, F=5.66, P=0.004]; and short times to first flatus[(2.7±0.8)d vs.(3.0±0.6) d, F=6.61,P=0.031],for liquid diet[(3.7±0.8) d vs.(4.0±0.6) d, F=7.35, P=0.022] and semifluid diet[(4.7±0.8)d vs. (5.0±0.6) d, F=6.43, P=0.013]. No perioperative death occurred in two groups; there were no significant differences in length of postoperative hospital stay [(9.4±4.2)d vs. (10.9±6.4) d, F=0.83, P=0.117]and the incidence of postoperative complication[5.8%(3/52) vs. 8.8%(7/80), χ2=0.40, P=0.527)]. Compared to BA group,alkaline reflex gastritis rate [3.8%(2/52) vs. 52.5%(42/80), χ2=40.04, P=0.000]and marginal ulcer rate were lower[0(0/52) vs. 11.3%(9/80), χ2=6.28,P=0.012]. There was no significant difference in dumping syndrome rate[0(0/52) vs. 3.8%(3/80), χ2=0.20, P=0.158] between two groups. Conclusion Uncut Roux-en-Y anastomosis can prevent alkaline reflex gastritis, marginal ulcer and Roux-en-Y stasis syndrome, it may be the preferable technique for reconstruction after total laparoscopic distal gastrectomy. Key words: Stomach neoplasms; Carcinoma; Laparoscopy; Gastrectomy; Anastomosis, Roux-en-Y

Reversal of Roux en Y gastric bypass: largest single institution experience

BackgroundThere is a paucity of literature on patients who have undergone reversal of Roux-en-Y gastric bypass (RYGB) to normal anatomy. We present the largest single institution experience with reversal of RYGB for serious chronic complications. ObjectiveTo describe our experience including indications, outcomes, and complications of RYGB reversal. SettingAcademic-affiliated private practice. MethodsRetrospective review of 48 patients who underwent laparoscopic reversal of RYGB between 2012 and 2016. ResultsNinety-six percent (n = 46) of patients were female, and the mean age was 48.6 (range, 23–72). Indications for reversal of RYGB included marginal ulcer (n = 25, 12 of whom were malnourished and 17 had coexisting substance abuse), malnutrition alone (n = 11), chronic pain and nausea (n = 7), and postprandial hyperinsulinemic hypoglycemia (n = 5). Overall 30-day complication rate was 29% (n = 14), including gastrogastric anastomotic leak (n = 5), sepsis (n = 5), and bleeding requiring transfusion (n = 3). Weight gain after surgery increased in all patients, especially those patients deemed severely malnourished. All patients reported resolution of symptoms leading to reversal of RYGB, although 58% of patients were lost to follow-up at 1 year after surgery. ConclusionsLaparoscopic reversal of Roux-en-Y gastric bypass is a complex revisional operation that can be safely performed in a select group of patients with serious complications. The main indications for reversal of RYGB included malnutrition with and without recalcitrant marginal ulcers. Weight gain and resolution of malnutrition occurred soon after reversal of gastric bypass. Because the complication rates are high, reversal should be considered only after all salvage attempts have failed. Reversal to normal anatomy carries high morbidity, including sepsis, leaks and bleeding, high reoperative rates, and readmission. Although reversal of RYGB has a role in the treatment of a select group of patients, it should be undertaken by surgeons with considerable experience in RYGB revision.

How to Incorporate Bariatric Training Into Your Fellowship Program.

How to Incorporate Bariatric Training Into Your Fellowship Program.

750 – Revisional Surgery for Recurrent Marginal Ulceration Following Roux-En-Y Gastric Bypass: Incidence, Outcomes and Healthcare Utilization

750 – Revisional Surgery for Recurrent Marginal Ulceration Following Roux-En-Y Gastric Bypass: Incidence, Outcomes and Healthcare Utilization

60 – Protein Pump Inhibitor Metabolism is Altered in a Significant Portion of Bariatric Candidates and May Be Associated with Early Marginal Ulceration After Gastric Bypass

60 – Protein Pump Inhibitor Metabolism is Altered in a Significant Portion of Bariatric Candidates and May Be Associated with Early Marginal Ulceration After Gastric Bypass

Laparoscopic One Anastomosis Gastric Bypass Versus Laparoscopic One Anastomosis Gastric Bypass with Braun Anastomosis: What's Better?

Background and Aims: Although laparoscopic one anastomosis gastric bypass (LOAGB) is a promising bariatric procedure, a large number of surgeons have strong objections mainly because of risk of bile reflux, marginal ulceration, malnutrition, and long-term risk of gastric and esophageal cancer. Lateral enteroenterostomy placed distally to a gastrojejunal anastomosis shows efficacy in preventing bile reflux after gastric resection and gastrojejunal anastomosis, but at present its efficacy in a bariatric surgery context has not been evaluated. Patients and Methods: From January 2013 to December 2018, 100 patients have been admitted to our department to be treated by performing LOAGB. Patients have been divided into two groups on the basis of the indications to this surgical procedure; Group A: presence of de novo gastroesophageal reflux disease (GERD) or severe esophagitis after laparoscopic sleeve gastrectomy, with or without weight regain; Group B: LOAGB as primary procedure. Another group of 30 patients (Group C) underwent LOAGB with Braun anastomosis as primary bariatric surgical procedure for morbid obesity. We have conducted a retrospective analysis of the surgical outcomes in terms of perioperative mortality, short-, mid-, and long-term postoperative complications and weight loss. Results: Group A: 50 patients; incidence of postoperative GERD, esophagitis, or esophageal ulcers was 26% (13 cases). All these patients have been successfully treated by performing Braun anastomosis. Group B: 20 patients; incidence of de novo reflux was 25% (5 cases); Braun anastomosis was performed with complete resolution of signs and symptoms in all cases. Group C: 30 patients; no cases of de novo reflux, esophagitis, or anastomotic ulcers occurred. Conclusion: Braun anastomosis seems to be a useful surgical tool to prevent the onset of de novo reflux, esophagitis, and anastomotic ulcers.

Limb Length in Gastric Bypass in Super-Obese Patients-Importance of Length of Total Alimentary Small Bowel Tract.

In super-obese patients, rates of weight loss failure and weight regain are high after RYGB. In order to improve weight loss, lengthening of the biliopancreatic limb is vital. In this study, efficacy and safety of two types of RYGB with 2-m BP-limb were assessed in improving weight loss and in the resolution of comorbidities compared with standard RYGB in a long-term follow-up. This is a retrospective cohort analysis on 671 super-obese patients operated in a 10-year period. Patients were classified into three groups: (1) 155 patients; roux limb 150cm, BP-limb 60cm; (2) 230 patients; roux limb 60cm, BP-limb 200cm; and (3) 286 patients; roux limb 150cm, BP-limb 200cm. EWL, TWL, BMI, failure, weight regain, comorbidity resolution, nutritional status, and complications were assessed. Total alimentary limb length was shortened with 60cm in group 1 and with 200cm in groups 2 and 3. EWL, BMI change, and TWL were higher in the 2-m BP-limb groups vs group 1. No differences in complication rates were found, except higher frequency of marginal ulcers in patients with a shorter roux limb. EWL failure was higher in group 1 (10.3%) vs the other groups (4.3%; 5.2%). Group 3 had significantly less weight regain (26.6%). Remission of comorbidities was higher in the 2-m BP-limb groups at expense of nutritional and vitamin deficiencies (3.9%; 5.9%). No difference in hypoalbuminemia was noted. Lengthening of the BP-limb gives significantly higher weight loss, lower rate of EWL failure, and lesser weight regain along with better resolution of obesity-associated comorbidities.

A population based analysis of proton pump inhibitor use following pancreaticoduodenectomy: What is the impact on marginal ulceration and gastrointestinal bleeding?

Background: Upper gastrointestinal bleeding (UGIB) and marginal ulceration (MU) are significant postoperative issues following pancreaticoduodenectomy(PD). The role of proton pump inhibitor(PPI) therapy in preventing complications remains uncertain. A survey (Butler et al, 2015) of PPI prescription practice by HPB surgeons demonstrated a degree of consensus; with 38% of surgeons preferring PPI therapy for 6 months or more and 48% preferring lifelong PPI therapy. The aim of this study was to assess how such opinions translate into real world practice. A population based analysis of adherence to PPI prescription following PD and its impact on MU and UGIB rates was therefore undertaken. Methods: A retrospective review of 319 PDs performed in one institution between January 2011 and December 2016 was performed. Demographic, intraoperative and postoperative outcome data were recorded using electronic hospital administrative databases and linked to hospital and community based pharmacy prescription databases to assess duration of PPI therapy and associated medications (non steroidal anti inflammatory drugs(NSAIDs), oral anticoagulants). The number of postoperative PPI prescription days was quantified and categorised into 6 monthly intervals. Univariate statistical analyses were then carried out to assess association between PPI duration with MU and UGI bleeding complications. Further assessment was also made of PPI prescription and outcome with a logistic regression model adjusted for standard demographic and perioperative factors. Analysis was with Stata v14 with the significance level set at p<0.05. Results: The mean age was 63.7years (SD 14) (52% male). Median follow up was 666 days (95%CI 606–72) and median postoperative stay 13 days (IQR 10 – 20). The major complication rate was 10.7%. The marginal ulceration rate was 3.1% (95% CI 1.5 –5.6%) and postoperative GI bleeding was 5% (95%CI 2.9–8%). Median time to development of GI bleeding / ulceration was 7.5 months (IQR 1–28 months). The in-hospital postoperative PPI prescription rate was 89%. In the community (post-discharge) the rate reduced to 68.4%. Adjusting for postoperative death during the same period; 50.8%, 41.3%, 27.8% of PD patients had prescribed PPI therapy for a minimum of 6 months, 1 year and 2 years respectively. Only 37% of patients were prescribed PPI therapy for greater than 50% of their follow-up period and only 13% of patients were prescribed PPI for the full duration of their follow-up period. Inpatient PPI therapy had no impact on in-hospital major complications (11.1% v 10.6% p = 0.93) and was associated with an increased hospital stay (12.2 days v 18.5 days p = 0.02). The prescription of postoperative PPI did not impact upon GI bleeding or marginal ulceration rates (2.5 v 3.3% p = 0.723 for MU and 2.5% v 5.8% p = 0.24 for GI bleed). When stratified by 6 monthly durations, PPI therapy had no impact on MU (OR 1.2 95%CI 0.8–1.8 p = 0.371). Total PPI use of between 6 months and 12months duration was associated an increased odds of GI bleeding (OR 1.4 1.1–1.97 p = 0.04). In a model adjusted for age, sex and NSAID use no association between PPI therapy duration and GI bleeding was observed (OR 1.37 95% CI 0.97–1.94 p = 0.17). Conclusion: The pattern of postoperative PPI use amongst patients undergoing PD is variable, with only a third of patients using PPI therapy for the majority of their postoperative course. In-patient PPI therapy does not alter early postoperative complication rates. Longer term PPI use does not appear to reduce post PD gastrointestinal bleeding or marginal ulceration complications. This population based analysis of PPI use has demonstrated a lack of efficacy for routine PPI prescription in preventing marginal ulceration and upper gastro intestinal bleeding complications following pancreaticoduodenectomy. The routine long term prescription of postoperative PPI therapy following PD requires further prospective evaluation.

Laparoscopic Repair of Perforated Marginal Ulcer After Roux-en-Y Gastric Bypass: A Case Report and Review of Literature

Introduction: A possible complication that may present late after Roux-en-Y gastric bypass is the development of marginal ulcer at the gastrojejunostomy site. We discuss here an emergency presentation of a case with a delayed perforation at the anastomosis 5 months after surgery which dealt successfully with the laparoscopic approach. Case Presentation: A 45-year-old female presented to the emergency department for evaluation of severe upper abdominal pain. Her past history was significant for laparoscopic Roux-en-Y gastric bypass surgery for weight loss done in Oct 2016 and further denied any history of chronic medication, alcoholism, smoking or any co-morbidity. She was examined and found to have a tenderness all over the abdomen with sluggish bowel sounds and decreased air entry at bases bilaterally, more so on the left side. Portable CXR revealed air under the diaphragm and an obliterated left costophrenic angle. A repeat CT scan with gastrograffin contrast was carried out and findings confirmed a perforation at the site of gastrojejunal anastomosis with free fluid in the pelvis and flanks. She underwent laparoscopic exploration and repair of anastomotic perforation with omental patch and was discharged in a healthy fashion on her 7th postoperative day. Conclusions: This case report corroborates with literature available from many sources that marginal ulcer perforation is one of the serious complications after Roux-en-Y gastric bypass and may present early in the first few months or as a delayed entity years after the surgery. Once diagnosed, urgent intervention is required and laparoscopic repair has shown itself a safe and effective treatment strategy where facilities are available.

Laparoscopic loop duodenaljejunal bypass with sleeve gastrectomy in type 2 diabetic patients

BackgroundLaparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a new metabolic procedure. Our initial data on type 2 diabetes (T2D) remission after LDJB-SG were promising. ObjectivesThe aim of this study was to look at our intermediate outcomes after LDJB-SG. SettingAn academic medical center. MethodsA prospective analysis of T2D patients who underwent LDJB-SG between October 2011 and October 2014 was performed. Data collected included baseline demographic, body mass index, fasting blood glucose, glycosylated hemoglobin, C-peptide, resolution of co-morbidities, and postoperative complications. ResultsA total of 163 patients with minimum of follow-up >1 year were enrolled in this study (57 men and 106 women). The mean age and body mass index were 47.7 (±10.7) years and a 30.2 (±5.1) kg/m2, respectively. There were 119 patients on oral hypoglycemic agents only, 29 patients were on oral hypoglycemic agents and insulin, 3 patients were on insulin only, and the other 12 patients were not on diabetic medication. Mean operation time and length of hospital stay were 144.7 (± 45.1) minutes and 2.4 (± 1.0) days, respectively. Seven patients (3.6%) needed reoperation due to bleeding (n = 1), anastomotic leak (n = 2), sleeve strictures (n = 2), and incisional hernia (n = 2). At 2 years of follow-up, there were 56 patients. None of the patients were on insulin and only 20% of patients were on oral hypoglycemic agents. Mean body mass index significantly dropped to 22.9 (±5.6) kg/m2 at 2 years. The mean preoperative fasting blood glucose, glycosylated hemoglobin, and C-peptide levels were 174.7 mg/dL (± 61.0), 8.8% (±1.8), and 2.6 (±1.7) ng/mL, respectively. The mean fasting blood glucose, glycosylated hemoglobin, and C-peptide at 2 years were 112.5 (±60.7) mg/dL, 6.4% (±2.0), and 1.5 (±0.6) ng/mL, respectively. No patient needed revisional surgery because of dumping syndrome, marginal ulcer, or gastroesophageal reflux disease at the last follow up period. ConclusionAt 2 years, LDJB-SG is a relatively safe and effective metabolic surgery with significant weight loss and resolution of co-morbidities.

Analysis of symptomatic marginal ulcers in patients who underwent Whipple’s operation for peri-ampullary tumors

Introduction: We investigated the incidence and risk factors associated with the development of marginal ulcers (MUs) after Whipple’s operation and analyzed their relationship with the use of prophylactic proton pump inhibitors (PPIs). Finally, our goal was to provide evidence of the effectiveness of prophylactic PPIs for preventing MUs after Whipple’s operation. Method: The study included 1338 consecutive patients. Clinico-postoperative outcomes of 72 MUs and 1266 non-MUs were compared and analyzed. We performed a sub-analysis of 72 patients with MU diagnosed within (n=18) and after 4 months (n=54). The risk factors associated with MU incidence were analyzed. Result: Of the 1338 patients, 72 (5.4%) were diagnosed as having MU. Over time, the incidence of MU decreased. Eighteen patients (25.0%) were diagnosed during the first 4 months; and 48 (66.7%), within 16 months. Cumulative MU incidence significantly differed according to the duration of prophylactic PPI use (≥4 months : 7.1% vs <4 months: 10.1%, p<0.001). The duration of prophylactic PPI use was identified as a risk factor in the multivariable analysis (hazard ratio, 2.294; 95% confidence interval, 1.436–3.664; p=0.001). Conclusion: MU was more frequent within 4 months after Whipple’s operation, but occurred even after 40 months. Two-thirds or more of the patients were diagnosed as having MU within 16 months after surgery. The duration of the prophylactic PPI use was an independent risk factor in the multivariable analysis. We therefore recommend the use of prophylactic PPIs for >16 months after Whipple’s operation for periampullary tumors.

Perforated Peptic Ulcer Happened after Robotic Assisted Pylorus-preserving Pancreaticoduodenectomy and Review of Literature

Introduction: Marginal ulceration is one of common complications in patient who received pylorus-preserving pancreaticoduodenectomy (PPPD). The variation of incidence rate was wide and it was related with different reconstruction method. In this presentation, we will share our experience on a case of perforated peptic ulceration 21months after robotic PPPD and review the literature. Method: An 80-year-old man presented with watery diarrhea followed by acute abdominal pain for two days. Physical examination revealed hypoactive bowel sounds, muscle guarding, diffused rebounding pain. Computed abdominal tomography scan with contrast showed pneumoperitoneum and small amount ascites, wall thickening at anastomosis of jejunum and proximal efferent loop. He was diagnosed with hollow organ perforation. His medical history was panbronchiolitis under Erythromycin 500mg QD, type 2 diabetes mellitus under insulin control for 8 years, HbA1c: 6.9% and periampullary vater tubular adenoma with foci of high grade dysplasia post robotic-assisted PPPD with reconstruction by Traverso’s method 21 months ago. Post-operative antacid medication was administered for 4 months. Result: The patient received emergent exploratory laparotomy. A 0.5 cm ulcerative perforation over anterior wall of jejunal side of gastro-jejunosotmy was noted during surgery. Simple closure of perforation and feeding jejunostomy were performed for this patient. After surgery, pantoprazole was administered. The patient was discharged on the 14th day after emergent surgery. The incidence of marginal ulceration after PPPD with reconstruction by Traverso’s method was 6.9% in several studies. From July 2017 to March, 2019, total 230 patients received robotic PPPD. There are 3 cases of marginal ulceration with perforation after robotic PD at our hospital, incidence rate was 1.3% (3/230). Conclusion: Since marginal ulcer could be one of the complications and even lead to perforation after robotic PD, routine antacid medication is recommended for each patient undergoing a major operation such as robotic PD although done by minimal invasive approach.