Marginal Ulcer Research Articles

Marginal Ulcer Perforation Following Laparoscopic Roux-en-Y Gastric Bypass

Marginal Ulcer Perforation Following Laparoscopic Roux-en-Y Gastric Bypass

Early and late complications after gastric bypass: A literature review

Over the last few decades, excess weight and obesity have become a considerable health problem that has a lasting impact on communities worldwide. According to the WHO, about 1.9 billion people over the age of 18 are overweight [32]. Obesity accounted for about 4.7 million premature deaths in 2017. Globally, obesity was associated with an increase in mortality rate from 4.5 % in 1990 to 8 % in 2017 [32]. Bariatric surgery is currently recognized as the most effective treatment option for morbid obesity. Over the past 10 years, gastric bypass surgery has proved more effective than any other surgical methods due to its optimal metabolic effects.
 The aim of the review is to carry out an analysis of literature data in order to identify main complications after gastric bypass in patients with obesity.
 The complication rate after bariatric surgery decreased from 10.5 % in 1993 to 7.6 % in 2006 [3]. The mortality rate after bariatric surgery was 0.08 % within 30 days after surgery and 0.31 % after 30 days [13]. According to the BOLD study (2010), for 57,918 bariatric operations, the complication rate was 6,240 (10.77 %) and the mortality rate was 78 (0.135 %), within 30 days after surgery — 0.089 %, within 90 days after surgery — 0.112 %. Roux‑en‑Y Gastric Bypass (RYGB) was carried out in 30,864 cases, and 4,588 (14.87 %) patients developed postoperative complications. Early complications include anastomotic leaks (0 — 5,6 % for laparoscopic approach and 1,6 — 2,6 % — for laparotomy), small bowel obstruction caused by a blood clot (0 — 0,5 %), bleeding from the sutures (1,5 %), and thromboembolic complications (0,2 — 5 %). Late complications include stenosis of the gastrointestinal tract (3 — 27 %), marginal ulceration (MU) — 0,6 — 16 %, an incarcerated Petersen’s space hernia — 2,51 %, perforation of the stomach and small intestine (1 — 2 %), gastrogastric fistula formation — 1,5 — 6,0 %, weight regain (to 17,1 %).
 Increasing global demand for bariatric surgery as the best option for the management of excess weight and obesity necessitates more detailed investigation of possible complications it may induce. Therefore, further research is required to develop and study new effective methods for prevention and treatment of complications after surgical treatment of patients with morbid obesity.

Evaluation of esophageal pathology in a group of patients 2 years after one-anastomosis gastric bypass (OAGB) — Cohort study

BackgroundOne-anastomosis gastric bypass (OAGB) is a well established surgical procedure for morbid obesity. There are ongoing speculations and a debate regarding biliary reflux (BR) following OAGB. Studies considered OAGB as a risk for symptomatic and asymptomatic BR and marginal ulceration. The aim of the study was to evaluate the rate of gastroesophageal reflux disease (GERD) and esophagitis in microscopic and macroscopic evaluations among post OAGB patients diagnosed by means of upper endoscopy (UE) with a mucosal biopsy, and to assess the influence of comorbidities and medical history on endoscopic findings. MethodsPatients operated between 1st January 2016 to 31st December 2017 were schedule, two years after OAGB for UE with a biopsy. In all cases, biopsies from the distal esophagus were obtained. All patients received a validated GERD-Health-Related Quality of Life questionnaire to assess their current symptoms. ResultsFifty patients were finally enrolled in the study. Twenty-four (48%) had grade A or B esophagitis. Four patients (8%) had endoscopically suspected esophageal metaplasia (ESEM). 34/50 (68%) patients had various histopathological esophageal changes, based on the conducted endoscopy, among which four cases of Barrett’s esophagus were observed. ConclusionsDespite the high rates of esophagitis in our cohort, most of the patients did not report any symptoms which confirm the thesis of the essential role of asymptomatic bile reflux following OAGB. Theoretically, chronic bile reflux can degenerate Barrett’s esophagus into esophageal cancer.

Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review.

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.

Vasoconstrictor nasal spray causing life-threatening complications after bariatric surgery: A case report

Introduction and importanceBariatric surgery is an evolving surgical field with increasing cases per year, as obesity is prevalent, especially in developed countries. Complication diagnosis and management can be challenging. Marginal ulcers and anastomosis perforation are rare, but their incidence is likely underestimated.Case presentationTo the best of our knowledge, we present the first case with a two and a half years history of recurrent ischemia, marginal ulcers, and recurrent perforation after laparoscopic omega loop gastric bypass, most likely due to an abuse of an over-the-counter (OTC) sympathomimetic nasal spray. The complications (Clavien-Dindo classification IIIb) caused the necessity of recurrent hospitalizations and diagnostic interventions and an open conversion into Roux-Y gastric bypass in a damage control manner.Clinical discussion and conclusionConclusively, we advocate evaluating drug abuse, including OTC medications that patients might not report on a daily-based medical history, as an etiology for marginal ulcers and anastomosis perforation, especially in late and recurrent cases.

Use of a novel helical tack system for the management of challenging upper gastrointestinal defects.

Background and AimsIncreasingly, gastroenterologists are being asked to assist in the closure of defects. Although there are several available tools that can be used for defect closure, there remains a need for devices that are easy to use, effective, and durable. The aim of this case series is to demonstrate the use of a novel helical tack system in the closure of upper GI defects.MethodsTwo cases of challenging upper GI defects were identified. One case involved a perforated duodenal ulcer, and the other involved a nonhealing marginal ulcer. In both cases, the helical tack system was used for defect closure.ResultsIn both cases, defect closure was achieved using the helical tack system; however, 2 series of tacks were required in each case. There were no adverse events. Neither patient has required additional surgical or endoscopic interventions.ConclusionsThe helical tack system is a new device that may be useful for the closure of challenging upper GI defects. Additional comparative studies are needed to better understand the advantages and disadvantages of this system relative to other closure tools.

S2191 Endoscopic and Medical Management of Actinomycosis Infection at the Gastro-Jejunal Anastomosis After Subtotal Gastrectomy With Roux-en-Y Reconstruction Resolves Chronic Abdominal Pain

Introduction: Roux-en-Y gastric bypass surgery (RYGB) is one of the most common type of gastric surgeries performed worldwide. Chronic post-operative abdominal pain post RYGB occurs in up to 30% of patients. We present an 82-year-old female with chronic abdominal pain post RYGB caused by actinomycosis infection at gastrojejunal anastomosis associated with suture material. Case Description/Methods: An 82-year-old female presented with persistent epigastric abdominal pain following subtotal gastrectomy with Roux-en-Y reconstruction for stage 1 gastric adenocarcinoma. She reported chronic abdominal pain within a year of surgery. Imaging with CT abdomen/pelvis was unremarkable and EGD demonstrated a marginal ulcer. She was started on PPI but abdominal pain worsened, requiring multiple hospitalizations, repeated imaging and endoscopies over the next 5 years following surgery without an identified etiology for her ongoing abdominal pain. Repeat EGD at our center showed resolution of marginal ulcer and nodularity at the gastrojejunal anastomosis with associated suture material. Biopsies of the nodule demonstrated Actinomycosis infection with acute inflammatory exudate. She was started on amoxicillin and repeat EGD was performed with removal of suture material using endoscopic suture cutters. Repeat biopsy confirmed Actinomyces infection of the anastomosis as well as colonization of suture material. Antibiotics were continued for a total of six months and her abdominal pain completely resolved. Repeat EGD after completion of therapy demonstrated no evidence of actinomycosis infection at the anastomosis. Discussion: Actinomycosis infection following RYGB surgery is an uncommon source of post-operative chronic abdominal pain. In our case, increase in gastric pH after RYGB surgery due to anatomical changes and PPI usage as well as retained suture likely predisposed to this infection. There may have been a delay in diagnosis due to difficulty in visualizing the suture material on repeat EGD as it was located behind a fold of the anastomosis. This reinforces the recommendation for careful inspection of the post-RYGB anastomosis when evaluating chronic post-operative abdominal pain. Prior cases of intra-abdominal Actinomyces infection after RYGB required prolonged antibiotics for greater than 12 months or surgical intervention. To our knowledge, this is the first reported case of Actinomyces at the gastrojejunal anastomosis successfully treated with endoscopic foreign body removal and six months of antimicrobials.

S3701 Case Report of Laparoscopic Repair of Perforated Marginal Ulcer After Roux-en-Y Gastric Bypass Surgery

S3701 Case Report of Laparoscopic Repair of Perforated Marginal Ulcer After Roux-en-Y Gastric Bypass Surgery

Late Stricture from Marginal Ulceration after Roux-en-Y Gastric Bypass: Endoscopic Complications and Surgical Management.

Late Stricture from Marginal Ulceration after Roux-en-Y Gastric Bypass: Endoscopic Complications and Surgical Management.

Phlegmon Formation due to Perforated Marginal Ulcer After One Anastomosis Gastric Bypass; Conversion to Roux-en-Y Gastric Bypass: a Video Case Report

One anastomosis gastric bypass is now an accepted bariatric procedure in many countries. A rare but serious complication of OAGB is perforation of marginal ulcer with 0.5-1% incidence that needs urgent diagnosis and intervention. In cases of complicated or refractory ulcers, conversion to RYGB could be a definitive therapy.

Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review.

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

Use of lumen-apposing metal stents (LAMS) in the management of gastro jejunostomy stricture following Roux-en-Y Gastric Bypass for obesity: a prospective series

BackgroundChronic strictures following Roux-en-Y Gastric Bypass (RYGB) are a troublesome complication that can lead to significant morbidity. The use of stents has been described but the need for X-ray and risk of migration have meant limited use in the management of these strictures. Lumen apposing metal stents (LAMS) have traditionally been used for management of pancreatic pseudocysts. They don’t require X-ray and are easy to deploy with a short learning curve. This paper explores the use of LAMS to treat post RYGB strictures and explores their safety and efficacy.MethodsA prospective study over a 4-year period looking at 14 patients with post RYGB strictures. These patients were privately insured patients operated within a tertiary Private facility. The patients were followed up for between 1 and 3 years. We have prospectively collected data on the efficacy and safety of LAMS in these patients. Patients were followed up until stent removal or definitive surgery to correct a stricture.Results421 patients underwent RYGB in the study period. 14 (3.3%) of these patients developed a stricture that resulted in insertion of LAMS. There was no immediate complications and 12 patients had complete resolution of their stricture. There were no reoperations due to migration related issues although a migration rate of 19% was noted. 2 patients required surgery to correct refractory strictures not relieved by a LAMS stent, both of these were strictures associated with marginal ulceration of the gastro jejunostomy.ConclusionLAMS are a safe and effective method to manage post RYGB strictures. They have a high rate of resolution of strictures and can be safely deployed across strictures with no immediate complication. Migration does still appear to be a problem, however, does not appear to affect patient outcome or increase morbidity. Insertion is straightforward and doesn’t appear to be associated with a long learning curve.

Five-year review of ocular Neisseria gonorrhoeae infections presenting to ophthalmology departments in Greater Glasgow & Clyde, Scotland.

As gonococcal infections continue to increase, we wanted to review the number and clinical course of recent ocular gonococcal cases presenting to ophthalmology departments in NHS Greater Glasgow and Clyde. A 5-year retrospective review of adult ocular gonococcal cases, where the diagnosis of Neisseria gonorrhoeae was made on microbiological culture, was undertaken. Fifteen cases were identified (80% male). Average age was 26 years (range 17-42; median 24). Most common presenting features included purulent discharge (14/15; 93%), haemorrhagic conjunctivitis (10/15; 67%) and pre-septal cellulitis (9/15; 60%). Corneal involvement was documented in 5 (33%), with marginal ulceration in 1 (7%) but none had corneal perforation. Most common systemic treatment was IV ceftriaxone, alone or in combination with another antibiotic (6/15; 40%), followed by IM ceftriaxone, alone or in combination with another antibiotic (5/15; 33%). Median time from presentation to treatment was 1 day (0-23). All patients were referred or recommended to attend sexual health services. Seven patients (47%) attended and received complete sexually transmitted infection (STI) testing and contact tracing: 3 patients had systemic treatment initiated or changed at this visit and 1 patient had concurrent syphilis identified. This series confirms purulent conjunctivitis and cellulitis as the main presenting features of ocular gonococcal infection requiring hospital review. Early identification with appropriate systemic antibiotic treatment avoided corneal melting in this cohort. As concurrent STIs were identified and/or treatments changed in 4/7 (57%) following sexual health review, we recommend a shared care approach between ophthalmology, microbiology and sexual health services to effectively address all management issues.

Incidence and prognostic factors for the development of symptomatic and asymptomatic marginal ulcers after Roux-en-Y gastric bypass procedures

Abstract Objective Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU. Methods All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively. Results 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m2. Median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58 – 26.2) postoperatively and 24.4% of patients with MU were asymptomatic. 76.7% of MUs were located on the side of the Roux-limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively. Conclusion MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

Gastro-colic Fistula: a Rare Complication of a Marginal Ulcer Following One Anastomosis Gastric Bypass.

Gastro-colic Fistula: a Rare Complication of a Marginal Ulcer Following One Anastomosis Gastric Bypass.

Retrocolic retrogastric ROUX-EN-Y gastric bypass: how I do it.

Technical variations of the laparoscopic Roux-en-Y gastric bypass may influence the incidence of complications such as fistulas, marginal ulcers, stenosis, and internal hernias. We described the technical aspects of a retrocolic, retrogastric, laparoscopic gastric bypass procedure with manual gastrojejunostomy and the closure technique for the three mesenteric defects generated by the Roux-en-Y limb reconstruction. We summarized the data from 587 patients concerning complications directly related to the surgical technique. There were no internal hernias in patients followed, and in only 2 cases, small bowel obstruction related to defect closure occurred. The retrocolic, retrogastric gastric bypass performed with a meticulous closure of all three mesenteric defects reflects a low incidence of internal hernias and low complication rates related to the closure itself. The technique also allows less tension at the gastrojejunostomy.

High-risk bariatric candidates: does red-flagging predict the post-operative course?

Standards for preoperative bariatric patient selection include a thorough psychological evaluation. Using patients "red-flagged" during preoperative evaluations, this study aims to identify trends in long-term follow-up and complications to further optimize bariatric patient selection. A multidisciplinary team held a case review conference (CRC) to discuss red-flagged patients. A retrospective chart review compared CRC patients to control patients who underwent bariatric surgery in the same interval. Patients under 18 years old, undergoing revisional bariatric surgery, or getting band placement were excluded. High-risk characteristics causing CRC inclusion, preoperative demographics, percent follow-up and other postoperative outcomes were collected up to 5 years postoperatively. If univariate analysis revealed a significant difference between cohorts, multivariable analysis was performed. Two hundred and fifty three patients were red-flagged from 2012 to 2013, of which 79 underwent surgery. After excluding 21 revisions, 3 non-adult patients, and 6 band patients, 55 red-flagged patients were analyzed in addition to 273 control patients. Patient age, sex, initial BMI, ASA, and co-morbidities were similar between groups, though flagged patients underwent RYGB more frequently than control patients. Notably, percent excess BMI loss and percent follow-up (6 months-5 years) were similar. In multivariable analysis, minor complications were more common in flagged patients; and marginal ulcers, endoscopy, and dilation for stenosis were more common in flagged versus control patients who underwent RYGB. Perforation, reoperation, revision, incisional hernia, and internal hernia were statistically similar in both groups, though reoperation was significantly more common in patients with multiple reasons to be flagged compared to controls. Bariatric patients deemed high risk for various psychosocial issues have similar follow-up, BMI loss, and major complications compared to controls. High-risk RYGB patients have greater minor complications, warranting additional counseling of high-risk patients.

Impacts of Gastrojejunal Anastomotic Technique on Rates of Marginal Ulcer Formation and Anastomotic Bleeding Following Roux-en-Y Gastric Bypass.

Marginal ulceration (MU) and bleeding are possible complications following laparoscopic Roux-en-Y gastric bypass (RYGB). Our institution utilizes three techniques for performing the gastrojejunal anastomosis (GJA), providing a means to compare postoperative MU and bleeding as it relates to GJA technique. We sought to analyze the incidence of MU and bleeding between the 25-mm end-to-end anastomosis (EEA) stapler, linear stapler (LS), and robotic hand-sewn (RHS) GJA techniques. Electronic health records for all patients who had an upper endoscopy (EGD) after RYGB were queried (2010-2014). Charts were retrospectively reviewed for type of GJA, complications, endoscopic interventions, and smoking and NSAID use. Out of 1112 RYGBs, the GJA was created using an EEA, LS, or RHS approach in 58.6%, 33.6%, and 7.7% of patients, respectively. 17.4% had an EGD (19.9% EEA, 13.9% LS, and 14.0% RHS). Incidence of MU was 7.3% (9.3% EEA, 4.8% LS, and 5.8% RHS). Rates of EGD and MU were significantly higher after EEA vs. LS GJA (p<0.05). The bleeding rate was 1.5%, [1.1% EEA, 2.1% LS, and 2.3% RHS (p=NS)]. MU within 90 days of RYGB occurred in 4.1%, 0.8%, and 4.7%, respectively (p<0.05 for EEA vs LS only). NSAID and cigarette use were identified in 29.3%, 38.9%, and 60% and 17.2%, 22.2%, and 20%, respectively, for the EEA, LS, and RHS GJA (p=NS). The method of GJA has an impact on rate of MU formation. A GJA fashioned with a 25-mm EEA stapler tends to have higher rates of EGD and MU.

Incidence and Prognostic Factors for the Development of Symptomatic and Asymptomatic Marginal Ulcers After Roux-en-Y Gastric Bypass Procedures

Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU. All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5years postoperatively. In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40years and median initial body mass index of 41kg/m2. The median time to follow-up was 2.99years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2months (4.58-26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively. MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

Clinical and Endoscopic Predictors of Hydrostatic Balloon Dilation Failure for Post-Bariatric Anastomotic Stricture Treatment

Roux-en-Y gastric bypass (RYGB) patients can develop anastomotic strictures. The initial management relies on endoscopic hydrostatic balloon dilation, but in a subset of patients, it may be unsuccessful despite several dilations, requiring a different treatment modality. We evaluated the factors associated with balloon dilation failure and need for revision surgery. Retrospective analysis from patients presenting with a post-RYGB anastomotic stricture who underwent balloon dilation from 2005 to 2018 at Cleveland Clinic Florida and Cleveland Clinic Main Campus. Demographic, clinical, surgical, endoscopic, and post-procedural variables were collected. Univariate and multivariate analysis with odds ratio (OR) and 95% confidence interval (95% CI) calculation for factors associated to dilation failure was performed. Eighty-nine patients were included in the analysis. Population was predominantly white (85.4%) and female (87.6%), with mean age 46.4 years and followed for a mean of 97.4 months. All patients presented dysphagia, with mean stricture diameter of 7.7 mm and associated marginal ulcer in 69%. Successful dilation was achieved in 65 patients, while 24 patients had dilation failure and underwent revisional surgery. Multivariate analysis showed a higher risk of dilation failure if time from RYGB to first dilation was >3 months (OR 4.95, 1.29-19.04; p = 0.02), and if nausea/vomiting were present before first dilation (OR 4.37, 1.11-17.16; p = 0.03). One patient had a perforation after dilation and was treated surgically. Post-RYGB anastomotic strictures can be successfully treated with hydrostatic balloon dilation. However, patients with dilations performed > 3 months after initial RYGB and nausea/vomiting have an increased risk of dilation failure and need for further interventions.