Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass

Variation in utilization of acid-reducing medication at 1 year following bariatric surgery: results from the Michigan Bariatric Surgery Collaborative

BACKGROUND

Morbidly obese patients undergoing bariatric surgery have high rates of gastroesophageal reflux and are often treated with acid-reducing medications (ARM) such as proton pump inhibitors or H2-blockers. The objective of this study was to evaluate the effect of bariatric procedures on the utilization of ARM. We analyzed data from the clinical registry of the Michigan Bariatric Surgery Collaborative on 35,477 patients undergoing bariatric surgery between January 2006 and October 2012 who completed both baseline and 1-year follow-up surveys. Procedures included laparoscopic adjustable gastric banding (LAGB, n=2,627), Roux-en-Y gastric bypass (RYGB, n=6,410), sleeve gastrectomy (SG, n=1,567), and biliopancreatic diversion with duodenal switch (BPD/DS, n=162).

METHODS

Rates of ARM at 1 year by procedure type were compared using logistic regression analysis. Models were adjusted for patient characteristics, baseline co-morbidities, weight loss, and hiatal hernia repair.

RESULTS

Overall ARM use at baseline was 37.7% and declined to 29.6% at 1 year after bariatric surgery. The proportion of patients starting an ARM at 1 year when they were not using one at baseline by procedure was LAGB (13.9%), RYGB (19.2%), SG (21.6%), and BPD/DS (26.7%). The proportion of patients discontinuing an ARM at 1 year when they were using one at baseline by procedure was LAGB (55.6%), RYGB (56.2%), SG (37.3%), and BPD/DS (42.1%). Compared with LAGB on multivariable analysis, the likelihood of ARM use at 1 year was higher for SG (OR 1.70, 95% CI 1.45-1.99) and BDP/DS (OR 1.53, CI .97-2.40) but not different for RYGB (OR 1.02, CI .90-1.16).

CONCLUSION

Overall ARM use decreases after bariatric surgery; however, it is not uniform and depends on procedure type. SG is a significant predictor for ARM use at 1 year.

Delayed massive bleeding two years after Roux-en-Y gastric bypass

Delayed massive bleeding from an ischemic ulcer after Roux-en-Y gastric bypass is a rare and challenging event for the gastroenterologist as well as the bariatric surgeon.

Introduction:

Delayed massive bleeding from an ischemic ulcer is a complication after Roux-en-Y gastric bypass (RYGB). Ischemic ulcers that present with massive bleeding are rare and challenging for the gastroenterologist as well as the bariatric surgeon.

Case Description:

This report reviews the case of a 63-year-old man who underwent an uncomplicated laparoscopic RYGB for morbid obesity and experienced two episodes of massive hemorrhage after the procedure, almost 1 year apart.

Conclusion:

To our knowledge, there are only a few such specific cases reported. Here, we describe the treatment and outcome for such a case and present a review of the literature.

Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?

BACKGROUND

Roux-Y Gastric Bypass is a frequently used technique in bariatric surgery. Postoperative anatomy is altered by exclusion of the stomach, which makes this organ inaccessible for future esophagogastroduodenoscopy (EGD). The value of preoperative assessment of the stomach is unclear. Some institutions choose to investigate the future remnant stomach by EGD, others do not. Aim of the present study is to quantify the yield of preoperative EGD in our institution.

METHODS

Patients, planned for primary laparoscopic Roux-Y Gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy from December 2007 until August 2012, were screened by EGD in advance. Results of EGD and patient characteristics were retrospectively analyzed and categorized according to a classification system based on intervention needed.

RESULTS

523 patients (122 male, 401 female, mean age 44.3 years, average BMI 46.6) underwent preoperative EGD. In 257 patients (48.9%) no abnormality was found (group A), 117 patients (17.2%) had abnormalities without treatment consequences (B1), 84 patients (of the 326 tested [comment #1, reviewer #1, 26.8%] were H. Pylori positive (B2), in 75 (14.3%) treatment with proton pump inhibitors was required (B3), 6 (1.1%) required follow up EGD before surgery (C). For1 patient (0.2%) the operation was canceled because preoperative EGD presented with Barrett's esophagus with carcinoma (D). When all abnormalities were taken into account, baselines did show a significant difference for age, gender and reflux symptoms.

CONCLUSION

Standard preoperative assessment by EGD in patients who are planned for bariatric surgery is not indicated. The number needed to screen to find clinically significant abnormalities is high.

Catastrophic bleeding from a marginal ulcer after gastric bypass

The authors describe a case of life-threatening hemorrhagic marginal ulcer eroding into the splenic artery that required surgical intervention.

Marginal ulceration at the gastrojejunal anastomosis is a common complication following Roux-Y gastric bypass (RYGB). Hemodynamically significant hemorrhagic marginal ulcers are usually treated either endoscopically or surgically. We describe a unique case of life-threatening hemorrhagic marginal ulcer eroding into the main splenic artery. This condition was initially managed with angiographic embolization, followed by surgical intervention.

Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass

BACKGROUND

Marginal ulcer formation remains a significant complication of Roux-en-Y gastric bypass (RYGB). Up to 1 % of all RYGB patients will develop free perforation of a marginal ulcer. Classically, this complication has required anastomotic revision; however, this approach is associated with significant morbidity. Several small series have suggested that omental patch repair may be effective. The aim of this study was to examine the management of perforated marginal ulcers following RYGB.

METHODS

All patients who underwent operative intervention for perforated ulcers between 2003 and 2011 were reviewed. Those with a history of RYGB with perforation of a marginal ulcer were included in the analysis. Data collected included operative approach, operative time, blood loss, length of hospital stay, complications, smoking history, and steroid or NSAID use.

RESULTS

From January 2003 to December 2011, a total of 1,760 patients underwent RYGB at our institution. Eighteen (0.85 %) developed perforation of a marginal ulcer. Three patients' original procedure was performed at another institution. Eight patients (44 %) had at least one risk factor for ulcer formation. Treatment included omental patch repair (laparoscopic, n = 7; open, n = 9) or anastomotic revision (n = 2). Compared to anastomotic revision, omental patch repair had shorter OR time (101 ± 57 vs. 138 ± 2 min), decreased estimated blood loss (70 ± 72 vs. 250 ± 71 mL), and shorter total length of stay (5.6 ± 1.4 vs. 11.0 ± 5.7 days).

CONCLUSIONS

Perforated marginal ulcer represents a significant complication of RYGB. Patients should be educated to reduce risk factors for perforation, as prolonged proton pump inhibitor therapy may not prevent this complication in a patient with even just one risk factor. In our sample population we found laparoscopic or open omental patch repair to be a safe and effective treatment for this condition and it was associated with decreased operative time, blood loss, and length of stay.

Effectiveness of Thoracoscopic Truncal Vagotomy in the Treatment of Marginal Ulcers after Laparoscopic Roux-en-Y Gastric Bypass

Marginal ulcer is a significant complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Most marginal ulcers resolve with medical management, but nonhealing ulcers may require revision of the gastrojejunostomy, a procedure with significant morbidity and mortality. Traditionally, surgical therapy for refractory peptic ulcers includes a vagotomy. The current study evaluates the effectiveness of thoracoscopic truncal vagotomy (TTV) in the management of refractory marginal ulcers. All patients at two institutions with an intractable marginal ulcer after LRYGB treated with TTV between 2003 and 2010 were reviewed. Data were collected from chart review and telephone interview. Seventeen patients (mean age, 39 ± 13 years; 16 females) were diagnosed with marginal ulceration a median of 18 months after LRYGB and proceeded to TTV at a mean of 39 ± 43 weeks (range, 1 to 114 weeks) after the diagnosis. The median operative time was 89 ± 65 minutes (range, 45 to 318 minutes). Four patients had a complication (sympathetic contralateral pleural effusion, pneumothorax, operative bleeding, and readmission for emesis). Eleven patients had follow-up of 3 months to 6 years (median, 7 months). Nine patients (82%) had symptomatic improvement and/or endoscopic resolution, whereas two (18%) did not. No patient had endoscopic evidence of persistent or recurrent marginal ulcer. TTV achieves symptomatic improvement and/or endoscopic resolution of intractable marginal ulcers in over 80 per cent of patients status post gastric bypass and therefore offers a less morbid alternative to revision of the gastrojejunostomy.

Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned?

BACKGROUND

The definition of marginal ulcer after Roux-en-Y gastric bypass (RYGB) is widely debated. This study reviewed findings of upper endoscopy in symptomatic patients at a quaternary bariatric referral center. Further investigation included symptom constellation, potential etiologies, and efficacy of treatment for patients found to have marginal ulcer.

METHODS

Patients presenting for upper gastrointestinal endoscopy after Roux-en-Y gastric bypass were included in this study. An institutional review board-approved database was queried for the period 1 June 2010 to 31 August 2011. Subgroup analysis was performed for patients with marginal ulcer. Statistical analysis was performed using PASW version 18 for Windows.

RESULTS

During the study period, 455 upper gastrointestinal endoscopies were performed for 328 consecutive symptomatic patients. Marginal ulcer, found in 112 patients (34 %), was diagnosed for 59 of the patients (53 %) within 12 months after surgery and for 53 of the patients (47 %) more than 12 months after surgery. In patients found to have marginal ulcer, the most common presenting symptoms were pain, dysphagia, nausea, and vomiting. All the patients with marginal ulcer underwent acid suppression and cytoprotective therapy. Using uni- and multivariate analyses for healing, nonhealing, and healing with recurrence, tobacco use was found to be the solitary significant risk factor for recurrence (p = 0.01).

CONCLUSION

Patients with pain or dysphagia after gastric bypass warrant upper endoscopy given the high yield for abnormalities. Although the risk factors for the development of marginal ulcer remain multifactorial, a thorough investigation for potential etiologies including tobacco, alcohol, and nonsteroidal antiinflammatory drug (NSAID) usage should be determined and eliminated. The presence of multiple risk factors may pose a higher challenge in ulcer resolution, leading to increased recurrence. In the current series, prior or current tobacco use remained the sole independent risk factor for ulcer persistence.

Comparison of hand-sewn, linear-stapled, and circular-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

BACKGROUND

There is no consensus on the ideal gastrojejunostomy anastomosis (GJA) technique in laparoscopic Roux-en-Y gastric bypass (LRYGB). We reviewed our experience with three GJA techniques (hand-sewn (HSA), linear-stapled (LSA), and 25-mm circular-stapled (CSA)) to determine which anastomosis technique is associated with the lowest early (60-day) anastomotic complication rates.

METHODS

From November 2004 through December 2009, 882 consecutive patients underwent LRYGB using three GJA techniques: HSA, LSA, and CSA. All patients had a minimum of 2 months follow-up. Records were reviewed for postoperative gastrojejunostomy leak, stricture, and marginal ulcer, and these early complications were classified according to anastomosis technique. Multivariate analysis was performed to determine associations between complications and anastomosis technique.

RESULTS

Preoperative demographics, length of hospital stay, and postoperative follow-up did not differ between the three groups. The majority of patients underwent LSA (n = 514, 61.6%) followed by HSA (n = 180, 21.6%) and CSA (n = 140, 16.8%). Using multivariate analysis, there were no statistically significant differences in the rates of leak (LSA 1.0%, HSA 1.1%, CSA 0.0%, p = 0.480), stricture (LSA 6.0%, HSA 6.1%, CSA 4.3%, p = 0.657), or marginal ulcer (LSA 8.0%, HSA 7.7%, CSA 3.6%, p = 0.180).

CONCLUSIONS

The three techniques can be used safely with a low complication rate. Our data do not identify a superior anastomosis technique.

Late marginal ulcers after gastric bypass for morbid obesity. Clinical and endoscopic findings and response to treatment

Marginal ulcer (MU) is an occasional complication after gastric bypass which can occur early or late after surgery. In this study, we evaluated the incidence, clinical presentation, and endoscopic behavior of patients with late MU. Five hundred fifty morbidly obese patients were evaluated prospectively performing an endoscopic study 1-8 years after surgery. They were submitted either to laparotomic (n = 392) or laparoscopic (n = 158) approach. Six patients (1%) presented late MU 12 to 84 months after surgery. Four patients had single ulcer, while two patients had multiple ulcers. All were treated with proton pump inhibitors (PPIs). Several endoscopic evaluations were performed in each patient showing healing and no recurrence of the ulcer. Late MU occurs in a small proportion (1%) of patients submitted to gastric bypass. It can be single or multiple. Medical treatment with PPIs achieves healing at a mean time of 7 months. Several endoscopic evaluations should be performed in these patients in order to demonstrate healing of the ulcer and no recurrence.

[Follow-up after bariatric surgery]

BACKGROUND

The number of bariatric surgical procedures in Norway is increasing. Patients who undergo bariatric surgery may experience surgical, medical and nutritional complications. Follow-up of these patients is therefore important.

METHODS

The article is based on non-systematic literature searches in PubMed and on the clinical experience of the authors.

RESULTS

Bariatric surgery induces significant and sustained weight loss and improves obesity-related disorders. Gastric bypass is the most commonly performed bariatric procedure in Norway. This procedure is associated with a 30-day mortality of below 0.5 %, while severe complications occur in approximately 5 % of patients. Late complications include internal herniation, intestinal ulcers and gallbladder disease. After surgery all patients are given iron, vitamin D/calcium and vitamin B12 supplements to prevent vitamin and mineral deficiencies. Gastrointestinal symptoms and postprandial hypoglycaemia after surgery can be improved by dietary modifications, and the need for anti-diabetic and blood pressure lowering medications is reduced. Dose adjustment of other medications may also be necessary. Pregnancy is not recommended during the first year after bariatric surgery. Many patients need plastic surgery after the operation.

INTERPRETATION

Complications after bariatric surgery may manifest in the long term. Regular follow-up is required. General practitioners should be responsible for follow-up in the long term, and should be familiar with common and serious complications as well as normal symptomatology after bariatric surgery.

Review article: the impact of bariatric surgery on gastrointestinal motility

BACKGROUND

Obesity is a major medical problem worldwide. Different treatment modalities have emerged to treat obese patients, but the best long-term results are achieved with bariatric surgery. Currently, the interventions most commonly performed are laparoscopic adjustable gastric banding (LAGB), Roux-en-Y- gastric bypass (RYGB) and sleeve gastrectomy.

AIM

To review the gastrointestinal motor complications associated with each of these types of bariatric interventions and the clinical implications of such complications.

METHODS

Search of medical database (PubMed) on English-language articles from January 1996 to March 2011. The search terms used were laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), roux-en-Y-gastric bypass (RYGB), using the AND operator with the terms: complications, motility, GERD, reflux, gastric emptying, esophagitis, dysphagia.

RESULTS

Of the three bariatric interventions reviewed, LAGB was the most studied. Most studies reported short follow-up, of ≤ 1 year. Oesophageal motor dysfunction is the most common motility complication following the bariatric interventions that were reviewed and is mainly observed after LAGB. Some data suggest that oesophageal motor function testing predicts development of post-operative symptoms and oesophageal dilation. RYGB offers protection from gastro-oesophageal reflux. Sleeve gastrectomy was the least studied and was associated with an acceleration of gastric emptying.

CONCLUSIONS

The effects of these interventions on GI motility should be considered when selecting patients for bariatric surgery. There is scant information regarding the overall effect of sleeve gastrectomy on gastro-oesophageal reflux patterns and oesophageal motility.

Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies

Bleeding is a potentially serious complication after Roux-en-Y gastric bypass (RYGB). Preventive measures and therapeutic strategies have not been adequately defined. We reviewed data on 742 consecutive patients treated at the University of California San Francisco to identify cases of early and late bleeding (less or greater than 30 days after surgery) after RYGB. Bleeding was defined as symptoms or signs of bleeding, associated with blood transfusion. We recorded patient characteristics, details of the operative technique, diagnostic approach, therapeutic strategies, and outcomes. Twenty-six patients (3.5%) had postoperative bleeding, which mostly occurred in the first 30 days postoperatively (N=19). Hematocrit decreased significantly from preoperative values (-5.2 ± 3.1 without bleeding vs. -14.8 ± 4.7 with, p<0.01). Type 2 diabetes was more prevalent in patients who had bleeding (58% vs. 32%, p=0.03). No other patient characteristics or details of the operative technique were associated with different rates of bleeding. Therapeutic intervention other than transfusion was needed for seven patients with early bleeding (36.8%) and for all patients with late bleeding. Four patients with early bleeding required reoperation. Early bleeding source was intraluminal in four patients, intraperitoneal in five, and self-limited and of unknown location in ten. Late bleeding occurred on average at 62.6 months (range, 5 to 300 months) after index surgery, five patients required reoperation, and the source was always intraluminal. Bleeding after RYGB may be from various anatomic sites; details of the operative technique were not associated with different rates of bleeding, and therapy should be tailored to suspected location of bleeding.

Reinforced circular stapler in bariatric surgery

In this study, the application of reinforced circular staplers reduced the incidence of gastrojejunal anastomotic complications in patients undergoing Roux-en-Y gastric bypass.

Background:

Roux-en-Y gastric bypass (RYGBP) is the most common procedure for weight loss surgery but has multiple complications. This study evaluates the use of reinforced circular staplers (RCS) and their effects on reducing gastrojejunal anastomotic complications.

Methods:

We conducted a retrospective chart review from January 2007 to November 2008. Laparoscopic RYGBP were performed in 287 patients. A comparison was made of the complications with and without the use of reinforced circular staplers. The comparison was between a nonreinforced circular stapler (NRCS) group comprising 182 patients and an RCS group comprising 105 patients.

Results:

Complications at gastrojejunal anastomosis were experienced by 15.3% of the patients; 9.5% were in the RCS group and 18.7% were in the NRCS group (P=0.026). Neither group had anastomotic leaks. Bleeding rate was 4.8% in the RCS group vs. 6.6% in the NRCS group. Ulcers occurred in 2.9% of the RCS group vs. 6.0% of the NRCS group. Stricture rate was 1.9% in the RCS group vs. 6.6% in the NRCS group.

Conclusion:

The application of RCS reduced the incidence of gastrojejunal anastomotic complications. Patients are twice as likely to develop complications when no RCS device is used (95% CI 1.03, 4.623). Therefore, it is beneficial to utilize RCS for the gastrojejunal anastomosis in RYGBP procedures.

Endoscopic management of common bariatric surgical complications

The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation. Endoscopists caring for these patients should become familiar with post-bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal/extra-luminal findings, and endoscopic management of common bariatric complications; this review addresses these issues. This review will discuss common presenting symptoms, luminal as well as extra-luminal findings and endoscopic management of common bariatric complications.

Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BACKGROUND

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

The role of endoscopy in bariatric surgery

Morbid obesity is a chronic disease of excess fat storage, characterised by premature death and obesity-associated co-morbidities. The results of the current non-surgical treatment to treat obesity are disappointing, but surgical approaches may achieve a durable and longstanding weight loss with resolution and improvement of co-morbidities. Gastrointestinal complaints and digestive complications may, however, increase and may require an actively involved gastroenterologist.

Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn?

BACKGROUND

Patients undergoing Roux-en-Y gastric bypass for the resolution of morbid obesity have significant medical sequelae related to their weight. One of the most common comorbid conditions is joint pain requiring the use of non-steroidal anti-inflammatory medications (NSAIDs). In addition to NSAIDs, patients may engage in behaviors such as smoking and alcohol misuse that increase the risk of long-term postoperative complications to include gastric perforation.

METHODS

Data on 1,690 patients undergoing gastric bypass surgery were collected prospectively and reviewed retrospectively.

RESULTS

We identified seven patients who presented to an emergency room and subsequently required emergent surgical intervention for repair of gastric perforation. Six of the seven cases involved use or abuse of NSAIDs.

CONCLUSION

Important characteristics were identified including the use of NSAIDs, alcohol use, and non-compliance with routine long-term postoperative follow-up. Identifying those patients at high risk may decrease the incidence of this potentially life-threatening complication.

Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity

BACKGROUND

Marginal ulcer (MU) is an occasional complication after gastric bypass. We studied the incidence of this complication by a prospective routine endoscopic evaluation.

METHODS

441 morbidly obese patients were studied prospectively. There were 358 women and 97 men, with mean age 41 years and mean BMI 43 kg/m(2). An endoscopic evaluation was performed in all 1 month after surgery, which was repeated in 315 patients (71%) 17 months after surgery, independent of the presence or absence of symptoms. Patients were submitted either to laparotomic resectional gastric bypass (360 patients), employing a circularstapler-25 or to laparoscopic gastric bypass (81 patients), in whom a hand-sewn anastomosis was performed.

RESULTS

One month after surgery, 15 patients (4.1%) of the 360 laparotomic gastric bypass and 10 (12.3%) of the 81 laparoscopic gastric bypass presented an "early" marginal ulcer (p < 0.02). Seven patients among the 25 with MU were asymptomatic (28%). Endoscopy was repeated 17 months after surgery. Among 290 patients with no early MU, one patient (0.3%) presented a "late" MU 13 months after surgery. From the 25 patients with "early" MU, one patient (4%) presented a "late" MU. All these patients were treated with PPIs.

CONCLUSION

By performing prospective routine endoscopic study 1 month and 17 months after gastric bypass, two different behaviors were seen regarding the appearance MU: (a) "early" MU, 1 month after surgery in mean 6% and (b) "late" MU, in a very small proportion of patients (0.6%). Among patients with "early" MU, those who had undergone resectional gastric bypass showed significantly less ulcers compared to those patients in whom the excluded distal gastric segment had been left in situ. The operative method may play a significant role in the pathogenesis of MU after gastric bypass.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Endoscopic suture removal at gastrojejunal anastomosis after Roux-en-Y gastric bypass to prevent marginal ulceration

BACKGROUND

After Roux-en-Y gastric bypass (RYGB) surgery, marginal ulcers develop in 3-23% of patients. Marginal ulcers can occur secondary to the use of nonabsorbable sutures to create the gastrojejunostomy. The suture can elicit a foreign body reaction that exposes it to the gastric lumen, irritating the mucosa. Surgical removal is mandated when medical therapy fails to resolve matters. Because endoscopic removal would be less invasive than laparotomy, a technique for the endoscopic removal of the suture was devised. Presented are the results of 6 patients who underwent this procedure.

METHODS

A computer search of all patients who had undergone laparoscopic RYGB was done and found 6 women who had undergone endoscopic suture removal. After a double-lumen endoscope was inserted through the mouth, a grasper was used to placed the suture under tension before transecting it with blunt-tip endoshears. The suture was then removed without difficulty. All patients were evaluated at 2 weeks and 6 months postoperatively.

RESULTS

Of the patients who underwent laparoscopic RYGB between June 2003 and June 2005 and presented with epigastric pain, 6 women underwent endoscopic stitch removal. These women had a mean age of 57 years, a mean initial body mass index of 55 kg/m(2), and had undergone laparoscopic RYGB a mean of 18 months before presentation. The patients, who had experienced new-onset epigastric pain and "heartburn," underwent endoscopic examination of the stomach, which showed visible suture at the gastrojejunal anastomosis, no ulceration, and edema, and underwent suture removal. No complications developed. At 6 months of follow-up, all patients were without symptoms and had normal findings on upper endoscopy.

CONCLUSION

The results of our study have shown that endoscopic suture removal is a feasible and effective means of treating epigastric pain and preventing the suture-induced marginal ulcers that can occur after RYGB.

Surgical management of gastro-gastric fistula after divided laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Gastro-gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial.

METHODS

A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006.

RESULTS

Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3-27). Morbidity in six patients (25%) was caused by pneumonia, n=2; wound infection, n=2; staple-line bleed, n=1; and subcapsular splenic hematoma, n=1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients.

CONCLUSION

Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.

Complications of bariatric surgery

PURPOSE OF REVIEW

Morbid obesity is an epidemic in the United States and parts of Europe, with severe health consequences. As the number of patients undergoing bariatric surgery has increased dramatically, it is crucial for the gastroenterologist caring for these patients to have a better understanding of the procedures, their unique complications and the proper management for these complications.

RECENT FINDINGS

The incidence of the most significant complications is calculated from recent publications. Radiological and endoscopic workup is useful for diagnosis. Endoscopic dilation of strictures is possible. Endoscopic intervention for selected leaks and fistulas has been reported.

SUMMARY

This review describes the most common types of bariatric surgery, discusses the complications that each can cause, and addresses the recommended approach for their work-up and management in order to better equip the gastroenterologist in dealing with this new field.

Bariatric surgery for morbid obesity--a cure for metabolic syndrome?

At present there is no single medication that targets the metabolic syndrome directly. Bariatric surgery, a treatment option for morbidly obese individuals who fail medical therapy, has been shown to be very effective in treating multiple aspects of the metabolic syndrome. The decrease in insulin resistance is because of significant weight loss and by enhancing secretion of gut hormones such as glucagon-like peptide-1 (GLP-1).

Revisional bariatric surgery for inadequate weight loss

When behavioral or anatomic issues are not present, revisional surgery should be approached with a goal of treating malnutrition or enhancing excess weight loss. Unfortunately, no randomized controlled trials currently exist to help the practicing bariatric surgeon choose which revisional procedure to perform. A review of the available literature was undertaken and compared with our standard practices to see if any guidelines could be devised. At our institution, patients who have failed jejunal-ileal bypass are reversed in the setting of malnutrition and converted to a sleeve gastrectomy (SG) followed by duodenal switch (DS) as a second stage procedure in the setting of inadequate weight loss. After failed vertical banded gastroplasty (VBG), patients are converted to a Roux-en-Y gastric bypass (RYGBP). After failed adjustable gastric band (AGB) placement, we perform RYGBP. In the super-obese, we leave the band in place or convert to a DS with band removal. In patients with failed RYGBP, we convert our patients to DS, but placement of an AGB may be an acceptable option.

Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients

BACKGROUND

Marginal ulceration after Roux-en-Y gastric bypass (RYGB) is diagnosed in 1% to 16% of patients. The factors predisposing patients to marginal ulceration are still unclear.

METHODS

A total of 260 patients who underwent laparoscopic RYGB were retrospectively reviewed. Data regarding demographics, comorbidities, body mass index (BMI), Helicobacter pylori infection, gastrojejunal (GJ) anastomotic leaks, postoperative bleeding, operative time, type of suture material, and marginal ulcer formation were collected. Fisher's exact test was used for statistical analysis of discrete variables, and Student's t-test was used for continuous variables. Statistical significance was set at an alpha of 0.05.

RESULTS

The overall marginal ulceration rate was 7%. Demographic data (age, gender distribution, BMI) did not differ significantly between patients who experienced marginal ulceration and those who did not (p > 0.05). Similarly, technical factors (choice of permanent or absorbable suture for the GJ anastomosis, attending as primary surgeon, robotic GJ, operative time, postoperative hematocrit drop) were not statistically different between the two groups (p > 0.05). Finally, the prevalence of comorbidities (diabetes, hypertension, obstructive sleep apnea, musculoskeletal complaints, dyslipidemia, gastroesophageal reflux disease [GERD] and peptic ulcer disease [PUD]) did not differ significantly between the two groups (p > 0.05). However, preoperative H. pylori infection, although adequately treated, was twice as common among the patients who had marginal ulceration (32%) as among those who did not (12%) (p = 0.02). All the patients who experienced marginal ulcers had complete resolution of symptoms with proton pump inhibitors and sucralfate. No reoperations were required for marginal ulceration.

CONCLUSION

Helicobacter pylori may potentiate marginal ulcer formation. The authors hypothesize that H. pylori damages the mucosal barrier in a way that persists postoperatively, which may precipitate marginal ulceration even when the organism has been medically eradicated.

Outpatient complications encountered following Roux-en-Y gastric bypass

Practitioners taking care of postoperative bariatric patients need to keep in mind all of the complications that this population faces to prevent unnecessary morbidity. Bariatric patients presenting postoperatively with abdominal pain, tachycardia, vomiting, tachypnea, and a sense of impending doom should be worked up aggressively to find the cause of their symptoms. Because the incidence of obesity is rising in children and adults, more patients will have surgery to help with their weight loss. Physicians caring for these patients must be able to diagnosis and treat their complications quickly and efficiently to prevent further complications.

Complications of antiobesity surgery

Bariatric surgery is an effective long-term treatment for patients who suffer from morbid obesity, the incidence of which is increasing in North America. Laparoscopic gastric bypass and laparoscopic adjustable gastric band placement are the two commonly performed bariatric procedures. This article discusses the indications for bariatric surgery and the early and late complications associated with these two procedures. Laparoscopic biliopancreatic diversion and laparoscopic sleeve gastrectomy are also briefly discussed.