Perforated Marginal Ulcer Research Articles

Marginal Ulcer Perforation after One Anastomosis Gastric Bypass: Surgical Treatment and Two-Year Outcomes.

Background: Marginal ulcer (MU) perforation is a chronic complication after One-anastomosis Gastric Bypass (OAGB). This study's purpose was to analyze patients undergoing OAGB revision due to MU perforation and describe the two-year outcomes. Methods: A retrospective analysis of a database in a single-tertiary hospital. All patients undergoing surgical revision due to MU perforation were included. Results: During the study period, 22 patients underwent OAGB revision due to MU perforation. The rate of MU perforation was 0.98%. The median age was 48 years and there were 13 men (59%). The median time from OAGB to MU perforation was 19 months with a median total weight loss of 31.5%. Nine patients (41%) were smokers. Omental patch (±primary closure) was performed in 19 patients (86%) and three patients (14%) underwent conversion to Roux-en-Y gastric bypass (RYGB). At a median follow-up of 48 months, three patients (14%) had recurrent MU diagnosis, of which one had a recurrent MU perforation. Four patients (18%) underwent conversion to RYGB during follow-up. Conclusions: MU perforation is a chronic complication after OAGB. In this cohort, most patients were men and likely to be smokers. Omental patch was effective in most cases. Recurrent MU rates at two years follow-up were acceptable.

Late complication of Roux-en-Y Gastric Bypass: Marginal ulcer perforation

In recent years, morbid obesity has tended to increase as a human problem. Surgical options are used in cases where medical treatments are not a solution. One of the surgical options is Roux en-Y gastric bypass surgery (RYGB). RYGB is more effective than other surgical options and is one of the most frequently preferred methods (1,2). We present a female patient who presented to our emergency department with marginal ulcer perforation 1 year after RYGB.

International survey on complications of religious fasting after metabolic and bariatric surgery

Religious fasting in Ramadan the 9th month of the lunar year is one of five pillars in Islam and is practiced for a full month every year. There may be risks with fasting in patients with a history of metabolic/bariatric surgery (MBS). There is little published evidence on the possible complications during fasting and needs stronger recommendations and guidance to minimize them. An international survey was sent to surgeons to study the types of complications occurring during religious fasting in patients with history of MBS to evaluate the risk factors to manage and prepare more evidence-based recommendations. In total, 21 centers from 11 countries participated in this survey and reported a total of 132 patients with complications occurring during religious fasting after MBS. The mean age of patients with complications was 36.65 ± 3.48 years and mean BMI was 43.12 ± 6.86 kg/m2. Mean timing of complication occurring during fasting after MBS was 14.18 months. The most common complications were upper GI (gastrointestinal) symptoms including [gastroesophageal reflux disease (GERD), abdominal pain, and dyspepsia], marginal ulcers and dumping syndrome in 24% (32/132), 8.3% (11/132) and 23% (31/132) patients respectively. Surgical management was necessary in 4.5% of patients presenting with complications (6/132) patients due to perforated marginal or peptic ulcer in Single Anastomosis Duodenoileostomy with Sleeve gastrectomy (SADI-S), one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG), obstruction at Jejunojenostomy after Roux-en-Y gastric bypass (RYGB) (1/6) and acute cholecystitis (1/6). Patients after MBS should be advised about the risks while fasting including abdominal pain, dehydration, and peptic ulcer disease exacerbation, and a thorough review of their medications is warranted to minimize complications.

Perforated Marginal Ulcer, Post Roux-En-Y Surgery without Risk Factors: A Case Report

A marginal ulcer is a commonly occurring complication of Roux-en-Y gastric bypass, with an occurrence rate of up to 16%. However, perforation of such ulcers is rare, affecting approximately 1% of cases and typically manifesting at a later stage. Moreover, risk factors, whether surgical or non-surgical, are present in nearly all patients reported in the literature, with only 0.2% found to have none. This case report focuses on a 32-year-old female patient who presented with severe left-sided abdominal pain. She had a history of undergoing Roux-en-Y surgery two years prior. A CT scan of the abdomen revealed the presence of free air and contrast leak, indicative of a perforated marginal ulcer. The patient subsequently underwent a laparoscopic repair of the marginal ulcer, involving the use of an omental patch. In patients experiencing recurrent abdominal pain, the suspicion of a marginal ulcer should arise, prompting the inclusion of upper endoscopy as part of the diagnostic workup. The feasibility of laparoscopic repair with an omental patch has been demonstrated, and patients are advised to undergo follow-up endoscopy. Doctors should have a high suspicion index for perforation of marginal ulcer with any patient after bariatric surgery despite the absence of risk factors.

S3320 Endoscopic Management of a Large Gastric Wall Defect Due to Anastomotic Marginal Ulcer Perforation

S3320 Endoscopic Management of a Large Gastric Wall Defect Due to Anastomotic Marginal Ulcer Perforation

Marginal Ulcer Perforation After One-Anastomosis Gastric Bypass: Case Report and Literature Review

Marginal Ulcer Perforation After One-Anastomosis Gastric Bypass: Case Report and Literature Review

IBCOx-8 Bile reflux after laparoscopic mini-gastric bypass; Is it really a major concern?

Abstract Background Laparoscopic mini gastric bypass MGB, first performed in late 1990s, become a popular bariatric procedure with proven comparable efficiency. Its popularity can be explained by many factors including: its technical simplicity and efficacy in weight loss compared to RYGB, its superiority in controlling metabolic syndrome compared to restrictive procedures and its efficacy as revision surgery for failed restrictive procedures. However, many debates still exist among bariatric surgery experts regarding its complications; mainly bile reflux and its consequences. We presented our experience, as a tertiary university institute in dealing with bile reflux complications after laparoscopic mini gastric bypass that necessitated endoscopic and/or operative interventions. Methods This is a retrospective study of all cases who were admitted in a tertiary hospital because of bile reflux related complications in one year duration. Results Three cases were admitted because of bile reflux complications. The first case presented by hemorrhagic shock due to massive hemorrhage at a marginal ulcer after 26 days of mini gastric bypass. The second case was re-operated electively because of intractable bile reflux after failure of medical treatment. The third case presented with peritonitis on top of perforated marginal ulcer seven month after mini gastric bypass. Conclusion Despite its claimed safety and efficacy, laparoscopic mini gastric bypass is not the procedure of no-morbidities. Incidence of postoperative bile reflux is under-estimated. All patients should undergo a regular endoscopy to assess it even if asymptomatic.

Revision Gastrojejunostomy Versus Suturing With and Without Omental Patch for Perforated Marginal Ulcer Treatment After Roux-en-Y Gastric Bypass

BackgroundUlceration at the gastrojejunostomy is a late bariatric surgery complication in 0.6–16% of Roux-en-Y gastric bypass (RYGB) patients. As there is no general consensus on management of acute ulcer perforations, we compare two methods of surgical repair: the most commonly performed procedure, suturing of ulcer with or without omental patch versus revision gastrojejunostomy (RG). MethodsA retrospective chart review of cases at a single large, Midwestern US high-volume bariatric center from November 2, 2006 through March 11, 2021 identified 144 RYGB patients undergoing surgical repair for a perforated ulcer: 72 treated by SGP and 72 by RG. Outcomes, including length of stay, leaks, readmissions, and reoperations, were compared. Categorical variables were compared by Chi-square tests and continuous variables by ANOVA. ResultsPatients were primarily female (77.1%) and Caucasian (97.2%), 49.7±12.5 years old, and 90.6±26.6 kg. Most had laparoscopic RYGBs (98.6%). There were no demographic differences between groups. Of the RG patients, 11.4% experienced ulcer recurrence versus 41.7% of SGP patients (p < .001), and 2.8% of RG versus 11.1% of SGP patients required a reversal (p < .05). No significant differences between groups occurred in time to perforation (3.2 vs. 2.5 years for RG and SGP groups, respectively), length of stay (5.0 vs. 6.8 days), leaks (1.4% vs. 2.8%), readmissions (4.2% vs. 4.2%), or reoperations (2.8% vs 5.6%). ConclusionsPatients developing perforated marginal ulcers after RYGB can be safely and effectively treated by revision gastrojejunostomy with a lower likelihood of ulcer recurrence. Short-term morbidity was comparable to suturing with or without an omental patch.

Perforated marginal ulcer after gastric bypass for obesity: a systematic review

Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal ulcers. We performed a systematic review to understand the presentation, management, and outcomes of PMUs. PubMed, Google Scholar, and Embase databases were searched to identify all studies on PMUs after gastric bypass procedures. A total of 610 patients were identified from 26 articles. The mean age was 39.8±2.59 years, and females represented most of the cohort (67%). The mean body mass index was 43.2±5.67 kg/m2. Most of the patients had undergone a Roux-en-Y gastric bypass (98%). The time gap between the primary bariatric surgery and the diagnosis of PMU was 27.5±8.56 months. The most common presenting symptom was abdominal pain (99.5%) and a computed tomography scan was the diagnostic modality used in 72% of the patients. Only 15% of patients were on prophylactic proton pump inhibitors or H2 blockers at the time of perforation, and 41% of patients were smoking at the time. Twenty-three percent of patients were on nonsteroidal anti-inflammatory drugs. Laparoscopic omental patch repair of the perforation (59%) was the most used technique; 18% of patients underwent open surgery, and 20% were managed non-surgically. Thirty-day mortality was 0.97%; it was 1.21% (n=5) and 0% (n=0) in those who were managed surgically and nonsurgically, respectively. Ulcers recurred in 5% of patients. In conclusion, PMU is a surgical emergency aftergastric bypass that can result in significant morbidity and even mortality. This is the first systematic review in scientific literature characterizing this condition.

Revisional Surgery After One Anastomosis/Minigastric Bypass: an Italian Multi-institutional Survey

BackgroundEfficacy and safety of OAGB/MGB (one anastomosis/mini gastric bypass) have been well documented both as primary and as revisional procedures. However, even after OAGB/MGB, revisional surgery is unavoidable in patients with surgical complications or insufficient weight loss.MethodsA questionnaire asking for the total number and demographics of primary and revisional OAGB/MGBs performed between January 2006 and July 2020 was e-mailed to all S.I.C. OB centres of excellence (annual caseload > 100; 5-year follow-up > 50%). Each bariatric centre was asked to provide gender, age, preoperative body mass index (BMI) and obesity-related comorbidities, previous history of abdominal or bariatric surgery, indication for surgical revision of OAGB/MGB, type of revisional procedure, pre- and post-revisional BMI, peri- and post-operative complications, last follow-up (FU).ResultsTwenty-three bariatric centres (54.8%) responded to our survey reporting a total number of 8676 primary OAGB/MGBS and a follow-up of 62.42 ± 52.22 months. A total of 181 (2.08%) patients underwent revisional surgery: 82 (0.94%) were suffering from intractable DGER (duodeno-gastric-esophageal reflux), 42 (0.48%) were reoperated for weight regain, 16 (0.18%) had excessive weight loss and malnutrition, 12 (0.13%) had a marginal ulcer perforation, 10 (0.11%) had a gastro-gastric fistula, 20 (0.23%) had other causes of revision. Roux-en-Y gastric bypass (RYGB) was the most performed revisional procedure (109; 54%), followed by bilio-pancreatic limb elongation (19; 9.4%) and normal anatomy restoration (19; 9.4%).ConclusionsOur findings demonstrate that there is acceptable revisional rate after OAGB/MGB and conversion to RYGB represents the most frequent choice.Graphical abstract

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

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

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.

Risk factors for perforated marginal ulcers following pancreaticoduodenectomy and prospective analysis of marginal ulcer development.

Perforated marginal ulcers (PMUs) are a feared long-term complication following pancreaticoduodenectomy (PD), which always require relaparotomy compared to marginal ulcers. First, we performed a retrospective chart review for all patients who underwent PD from 2007-2016 to identify incidence and risk factors associated with PMUs. Second, we analyzed follow up gastroscopies in all patients undergoing PD from 2007-2011 to identify the overall incidence of marginal ulcers. A total of 725 patients underwent PD in the retrospective study period. 17 patients (2.3%) suffered from PMU at a median postoperative time of 13 months. These patients were significantly younger (median age: 49 vs. 62 years; P=0.02) and suffered most often from chronic pancreatitis (P<0.001). Smoking and alcohol consumption were significantly more common (P=0.01 and P=0.023). An elevated level of carcinoembryonic antigen and chronic pancreatitis were identified as independent risk factors. Overall, 373 patients were enrolled for prospective analysis. Marginal ulcers occurred in 5-5.9% over a postoperative period of 5 years. Continuous treatment with proton-pump inhibitors for at least 5 years, immediate smoking cessation and follow-up gastroscopies are obligate for patients undergoing PD to avoid marginal ulcers and PMUs.

A rare complication of single anastomosis gastric bypass surgery: perforated marginal ulcer

A rare complication of single anastomosis gastric bypass surgery: perforated marginal ulcer

Marginal ulcer causing delayed anastomotic perforation following one anastomosis gastric bypass (OAGB).

One anastomosis gastric bypass (OAGB) is gaining favor. Anastomotic perforation is a dreaded complication. To describe a series of patients presenting with delayed (> 90 days) perforation of a marginal ulcer (MU) following OAGB. Two university hospitals, Israel. A retrospective query identifying patients after OAGB admitted with delayed MU perforation. Demographic characteristics, time between OAGB to presentation, clinical, laboratory and imaging at presentation and management data were collected. Between 1/2017-1/2020, 7 patients were identified. Mean body mass index (BMI) and time difference between OAGB and perforation were 14 kg/m2 (range 7-23) and 13 months (range 4-23), respectively. All presented with upper abdominal pain, 4 had concomitant nausea and vomiting. One patient displayed tachycardia, none had fever and 3 exhibited leukocyte abnormalities. C-reactive protein ranged widely (2-311 mg/L). Mean albumin level was 2.9 g/dL (range 1.9-4). Pneumoperitoneum was demonstrated in half of plain abdominal films and all computed tomography (CT) scans. Management was tailored to clinical status. Four patients underwent laparoscopic primary repair with omentopexy. Two patients were initially managed nonoperatively, one eventually requiring conversion to Roux-en-Y gastric bypass (RYGB) while the other recovered without further intervention. One patient underwent exploratory laparotomy and "damage control" management with pouch gastrostomy and double-barrel jejunostomy. Risk factors for MU were present in 4 cases. Mean length of hospital stay was 18 days (range 3-79 days). Perforation of MU may occur months to years after OAGB even without risk factors. Laboratory results are unreliable. The CT scan is diagnostic. A tailored approach can achieve goodoutcomes.

Perforation of anastomotic peptic ulcer following pancreaticoduodenectomy: a report of three cases

BackgroundPerforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention.Case presentationMarginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65–79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients.ConclusionsLack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Symptomatic marginal ulcer after pancreatoduodenectomy

BackgroundMarginal ulcer is a well-known complication after pancreatoduodenectomy. In light of increasing long-term survival after pancreatoduodenectomy, the identification of risk factors and preventive strategies are of utmost importance. We assessed the incidence, clinical impact, and potential risk factors of marginal ulcer after pancreatoduodenectomy. MethodsA prospectively maintained database of patients undergoing pancreatoduodenectomy was analyzed retrospectively. Univariate and bivariate competing-risk Cox regression analyses were performed to identify risk factors for marginal ulcer. ResultsTwo hundred and fifty-five consecutive patients underwent pancreatoduodenectomy. The median follow-up was 35.7 months. Marginal ulcer was diagnosed in 19 patients (7.5%), and the median time from pancreatoduodenectomy to marginal ulcer diagnosis was 450 days. Thirteen of these 19 patients presented with abdominal pain, melena, or anemia. In all these 13 patients, marginal ulcer resolved with proton pump inhibitor therapy and endoscopic surveillance. Six patients with marginal ulcer presented with an acute abdomen and underwent emergency laparotomy for marginal ulcer perforation and peritonitis. There was no marginal ulcer-related mortality. Univariate and bivariate competing-risk analyses showed an increased risk for marginal ulcer with discontinuation of proton pump inhibitor therapy, smoking, alcohol intake, and the use of non-steroidal anti-inflammatory drugs. Discontinuation of proton pump inhibitor therapy was an independent risk factor for marginal ulcer development. ConclusionMarginal ulcer is a relevant long-term complication after pancreatoduodenectomy that occurs more frequently after proton pump inhibitor therapy is discontinued. Based on our data, permanent use of proton pump inhibitor after pancreatoduodenectomy is strongly recommended especially for those patients who smoke, consume alcohol, or use non-steroidal anti-inflammatory drugs.

Perforated One Anastomosis Gastric Bypass, How We Managed and Review of Literature

: Marginal ulcer formation remains a common complication of the one anastomosis gastric bypass procedure, the ulcer can further perforate and present as peritonitis and although this is uncommon, it is considered one of the life threatening sequela associated with this surgery, we report here 2 different cases of perforated marginal ulcers that presented months after the procedure with acute abdomen, and discuss the surgical management using the laparoscopic approach to repair the perforation.

Spontaneous Gastrogastric Fistulalization After Being Left in Discontinuity of Proximal Gastric Pouch and Roux Limb Due to Catastrophic Gastrojejunal Marginal Ulcer Perforation

Spontaneous Gastrogastric Fistulalization After Being Left in Discontinuity of Proximal Gastric Pouch and Roux Limb Due to Catastrophic Gastrojejunal Marginal Ulcer Perforation

Endoscopic Stents in the Management of Bariatric Complications: Our Algorithm and Outcomes.

Endoscopic techniques can provide an alternative to surgery in the management of post-bariatric surgery complications such as leaks, strictures, fistulas, and erosion of transgastric and adjustable gastric bands. Endoscopically placed stents can also be used to manage gastric perforations secondary to NSAIDS or perforated marginal ulcers following gastric bypass surgery. Additionally, stents can be used in conjunction with operative intervention to decrease the risk of more deleterious complications that could require additional operations. The objective of this report is to describe our private practice experience in managing bariatric procedure complications with fully covered endoscopic stents. We present the algorithm we use in the application of endoscopic stents in the management of complications following bariatric surgery. Private practice, Single provider, Tertiary Referral Center, USA METHODS: Data for all patients who underwent endoscopic stent placement for complications after various bariatric surgeries (Roux-en-Y gastric bypass, gastric sleeve, lap band, and vertical banded gastroplasty) performed by several different surgeons between July 2015 and December 2018 at a single private practice were retrospectively reviewed. Patient's medical history, perioperative information, stent placement details, outcomes, and subsequent interventions were reviewed and analyzed. Thirty-five patients who were treated with endoscopic stents after bariatric surgery were identified. Complications after bariatric surgery treated with stenting included staple line leaks, anastomotic leaks, strictures, marginal ulcer perforations, gastrogastric fistula, and lap band erosion repairs. Mean duration of each stent round also varied. Resolution occurred in 33 patients (94.3%). Stent migration occurred in seven patients (20%) and in eight of 51 stents placed (15.7%). Two patients ultimately required revision surgery, though only one was related to stent (2.9%). Our findings suggest that foregut stents deployed according to our algorithm can facilitate healing of anastomotic leaks, staple line leaks, and marginal ulcer perforations. Furthermore, stent placement can also bolster tenuous repairs of band erosion sites, repairs staple line failure, and manages leaks at band erosion repair sites. Endoscopic stents can also be utilized to augment both balloon and savory dilation of gastric anastomoses and gastric sleeve strictures. Stents should be clipped proximally and distally to minimize the risk of migration.