NSAIDs and Ulcers After RNY
Articles on NSAIDs and ulcers after RNY surgery which demonstrate
why Duodenal Switch is preferred for patients requiring non
steroidal anti-inflammatory drugs post-op.
Perforated marginal ulcers after laparoscopic gastric
bypass.
Felix et al. Oct 2008
BACKGROUND: Perforated marginal ulcer (PMU) after laparoscopic
Roux-en-Y gastric bypass (LRYGB) is a serious complication,
but its incidence and etiology have rarely been investigated.
Therefore, a retrospective review of all patients undergoing
LRYGB at the authors’ center was conducted to determine the
incidence of PMU and whether any causative factors were present.
METHODS: A prospectively kept database of all patients at
the authors’ bariatric center was retrospectively reviewed.
The complete records of patients with a PMU were examined
individually for accuracy and analyzed for treatment, outcome,
and possible underlying causes of the marginal perforation.
RESULTS: Between April 1999 and August 2007, 1% of the patients
(35/3,430) undergoing laparoscopic gastric bypass experienced
one or more perforated marginal ulcers 3 to 70 months (median,
18 months) after LRYGB. The patients with and without perforation
were not significantly different in terms of mean age (37
vs 41 years), weight (286 vs 287 lb), body mass index (BMI)
(46 vs 47), or female gender (89% vs 83%). Of the patients
with perforations, 2 (6%) were taking steroids, 10 (29%) were
receiving nonsteroidal antiinflammatory drugs (NSAIDs) at
the time of the perforation, 18 (51%) were actively smoking,
and 6 of the smokers also were taking NSAIDs. Eleven of the
patients (31%) who perforated did not have at least one of
these possible risk factors, but 4 (36%) of the 11 patients
in this group had been treated after bypass for a marginal
ulcer. Only 7 (20%) of the 35 patients who had laparoscopic
bypass, or 7 (0.2%) in the entire group of 3,430 patients,
perforated without any warning. There were no deaths, but
three patients reperforated.
CONCLUSIONS: The incidence of a marginal ulcer perforating
after LRYGB was significant (>1%) and appeared to be related
to smoking or the use of NSAIDs or steroids. Because only
0.2% of all patients acutely perforated without some risk
factor or warning, long-term ulcer prophylaxis or treatment
may be necessary for only a select group of high-risk patients.
Seven cases of gastric perforation in Roux-en-Y gastric
bypass patients: what lessons can we learn?
Sasse et al. May 2008
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.
Predictors of endoscopic findings after Roux-en-Y gastric
bypass.
Wilson et al. Oct 2006
OBJECTIVES: To evaluate predictors of endoscopic findings
in symptomatic patients after Roux-en-Y gastric bypass (RYGBP)
for obesity.
METHODS: A retrospective chart review of 1,001 RYGBP procedures
was performed. Two hundred twenty-six (23%) patients were
identified as having endoscopy to evaluate upper gastrointestinal
symptoms following surgery. Polychotomous logistic regression
analysis was used to assess predictors of normal endoscopy,
marginal ulcers, stomal stenosis, and staple-line dehiscence.
RESULTS: The most common endoscopic findings were 99 (44%)
normal postsurgical anatomy, 81 (36%) marginal ulcer, 29 (13%)
stomal stenosis, and 8 (4%) staple-line dehiscence. Factors
that significantly increase the risk of marginal ulcers following
surgery include smoking (AOR = 30.6, 95% CI 6.4-146) and NSAID
use (AOR = 11.5, 95% CI 4.8-28). PPI therapy following surgery
was protective against marginal ulcers (AOR = 0.33, 95% CI
0.11-0.97). Median time for diagnosis of marginal ulcers
following surgery was 2 months, and 77 of 81 (95%) presented
within 12 months.
CONCLUSIONS: Following RYGBP surgery for obesity, smoking
and NSAID use significantly increase the risk of marginal
ulceration, and PPI therapy is protective. Because a significant
majority of marginal ulcers present within 12 months of surgery,
it may be reasonable to consider prophylactic PPI therapy
during this time period, especially for high risk patients.
Spectrum of endoscopic findings and therapy in patients
with upper gastrointestinal symptoms after laparoscopic
bariatric surgery.
Yang et al. Sept 2006
BACKGROUND: More should be known about the spectrum of endoscopic
abnormalities and treatments in patients with upper gastrointestinal
(UGI) symptoms after laparoscopic bariatric surgery.
METHODS: Patients referred for endoscopic evaluation of UGI
symptoms after laparoscopic bariatric surgery were studied.
Clinical manifestations, endoscopic findings and therapy
were recorded and correlated.
RESULTS: 76 patients who had undergone laparoscopic vertical
banded gastroplasty (LVBG) and 28 who had undergone laparoscopic
Roux-en-Y gastric bypass (LRYGBP) underwent 160 instances
of upper endoscopy. The symptoms included nausea or vomiting
(n=47, 29.4%), epigastric discomfort (n=44, 27.5%), UGI bleeding
(n=26, 16.3%), heartburn or acid regurgitation (n=26, 16.3%),
dysphagia (n=10, 6.3%) and anemia with dizziness (n=7, 4.4%).
The endoscopic diagnosis consisted of normal findings (n=57,
35.6%), marginal ulcer (n=39, 24.4%), erosive esophagitis or
esophageal ulcer (n=21, 13.1%), food impaction (n=21, 13.1%),
stenosis or stricture (n=14, 8.8%), gastric ulcer (n=7, 4.4%),
and duodenal ulcer (n=1, 0.6%). Patients with UGI bleeding,
dysphagia and LRYGBP tended to have endoscopic abnormalities
(P<0.001, P=0.09 and P=0.021, respectively). Endoscopic therapy
was successful in resolving the complications including stenosis,
UGI bleeding and food impaction.
CONCLUSIONS: Endoscopy is an essential method of combining
relevant endoscopic findings and therapeutic intervention in
symptomatic patients following laparoscopic bariatric surgery.
Incidence and management of marginal ulceration after
laparoscopic Roux-Y gastric bypass.
Gumbs et al. July 2006
BACKGROUND: Marginal ulceration (MU) is a well-known complication
after gastrojejunostomy; however, its incidence has rarely
been reported in bariatric studies. We present 16 cases of
documented MU after laparoscopic gastric bypass (LGBP) that
were successfully treated with proton pump inhibition (PPI).
METHODS: All patients undergoing LGBP from October 2002 to
August 2005 were entered into a prospective, longitudinal
database. All patients who subsequently presented with MU
were analyzed. MU was diagnosed when patients presented
postoperatively with mid-epigastric pain and/or upper gastrointestinal
bleeding that responded to PPI or endoscopic intervention.
Analysis of variance and Student’s t test were used for the
statistical analyses.
RESULTS: MU was diagnosed in 16 (4%) of 347 patients in whom
LGBP was performed. An additional 10 patients had symptoms
suggestive of MU, which raised the incidence as great as
7%. Of the 26 patients, 18 were women and 8 were men (age
range 23-53 years), with a preoperative body mass index
37.1-63.9 kg/m2, similar to that of the patients who did
not develop MU. Compared with the patients who did not develop
MU, the operative times were longer in the MU group (180.5
versus 140.4 minutes, P <0.001). Of the 26 patients, 10
presented with abdominal pain and 16 with upper gastrointestinal
bleeding. The mean interval between the initial LGBP and
subsequent MU was 6.3 months (range 1-13). After an initial
history and physical examination, upper endoscopy confirmed
the diagnosis of MU in 16 patients. Three patients who developed
MU were receiving chronic anticoagulation medication. All
patients who developed MU began high-dose PPI, which resulted
in 100% resolution of MU within 8 weeks. Since January 2005,
73 patients were given prophylactic PPI therapy postoperatively,
with no patients subsequently developing MU (P = 0.006).
CONCLUSION: We report 16 documented cases of MU occurring
after LGBP. This underreported complication can be successfully
treated with PPI, although MU complicated by gastrogastric
fistula may require operative intervention. The institution
of routine PPI therapy after LGBP lowered the short-term
incidence of MU at our institution. Additionally, we recommend
that all patients who undergo LGBP be given prophylactic PPI
therapy postoperatively.
Ulcer disease after gastric bypass surgery.
Dallal et al. July 2006
BACKGROUND: The mechanism of marginal ulceration after laparoscopic
gastric bypass surgery is poorly understood. We reviewed the
incidence, presentation, and outcome of ulcer disease in
consecutive patients undergoing laparoscopic gastric bypass
surgery.
METHODS: The outcomes of 201 consecutive laparoscopic gastric
bypass surgery procedures were prospectively analyzed for
complications. All procedures were performed using a linear
stapled anastomosis and absorbable suture.
RESULTS: The incidence of marginal ulcer disease was 3.5%
(7 patients). One patient, the only smoker, presented with
an acute perforation 4 months postoperatively. Three other
patients presented with bleeding-all required transfusion.
The remaining 3 patients presented with severe pain. At
endoscopy, all patients had ulcerations associated with the
Roux limb mucosa and were all successfully treated using
proton pump inhibitors and sucralfate therapy. Symptoms of
marginal ulceration occurred an average of 7.4 months (range
3-14) after surgery. The average follow-up was 19.8 months.
No preoperative factors were predictors of ulcer disease,
including body mass index, age, gender, or co-morbidities.
CONCLUSION: Marginal ulcers using the linear-stapled technique
occurred in 3.5% of patients. Three distinct clinical presentations
occurred: bleeding, pain, or perforation. No preoperative
risk factors were identified that predicted for this complication.
Medical management is an effective treatment.
Perforating marginal ulcers after laparoscopic gastric bypass.
Lublin et al. Jan 2006
BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LGB) can
be performed with minimal morbidity and mortality. This article
describes the first presentation of a known disease entity
after LGB: perforating marginal ulcers of the jejunum immediately
distal to the gastrojejunal anastomosis.
METHODS: A chart review of 902 LGB procedures performed by
a single surgeon between April 2000 and September 2004 identified
eight patients with perforating marginal ulcers.
RESULTS: The patients presented an average of 157 days (range,
53-374 days) after LGB. All the patients were treated using
laparoscopic primary closure followed by medical therapy.
Morbidity, in one patient only, consisted of two abdominal
fluid collections requiring separate drainage procedures.
There was no mortality. The average follow-up period was 13
months (range, 2-18 months). No patient experienced recurrent
ulceration.
CONCLUSIONS: Although the etiology is unclear, marginal ulcers,
a known complication of gastrojejunostomy, may present as
perforating ulcers after LGB in a characteristic fashion and
can be managed laparoscopically.
Role of gastric acid in stomal ulcer after gastric bypass.
Hedberg et al. Nov 2005
BACKGROUND: The pathogenetic mechanisms of stomal ulcer after
Roux-en-Y gastric bypass (RYGBP) are unclear. In order to
study the role of gastric acid, we measured acidity in the
proximal pouch using a pH-sensitive probe.
METHODS: 6 patients (5 females, mean age 45 years old at
time of operation) with endoscopically confirmed stomal ulcer,
were studied 2 to 6 years after RYGBP. All complained of
epigastric pain that improved during proton pump inhibitor
(PPI) therapy. Control subjects were 6 females (50 years old)
who had had RYGBP at least 5 years earlier and denied symptoms
of epigastric pain or heartburn. The pH-sensitive probe
(Digitrapper-pH, Medtronic) was passed through the nose to
the proximal pouch, guided by the calculated distance and
pH response. The probe was left in place for 4 hours. The
percentage of time with pH <4 was calculated.
RESULTS: The probe could be accurately positioned in the
proximal pouch both in symptomatic patients and in controls
as evidenced by the acid pH reaction. The proximal pouches
of patients with stomal ulcer were significantly more exposed
to acid compared to controls. The median percentage of time
with pH <4 was 69% and 20% in the stomal ulcer and the control
group, respectively (P<0.01). Barium follow-through excluded
gastro-gastric fistula in stomal ulcer patients.
CONCLUSION: RYGBP patients with stomal ulcer have increased
acid production in their proximal pouch in comparison with
asymptomatic RYGBP patients. Gastric acid appears to have an
important role in the pathogenesis of stomal ulcer.