Marginal Ulcer; Review Dr. Rutledge
06 Friday Jul 2012
Posted Marginal Ulcer
in06 Friday Jul 2012
Posted Marginal Ulcer
in27 Wednesday Jun 2012
Posted Marginal Ulcer
inLaparoscopic Gastric Pouch and Remnant Resection
A Novel Approach to Refractory Anastomotic Ulcers After Roux-en-Y Gastric Bypass: Case Report
Daniel C Steinemann; Marc Schiesser; Pierre-Alain Clavien; Antonio Nocito
From BMC Surgery
Laparoscopic Gastric Pouch and Remnant Resection
A Novel Approach to Refractory Anastomotic Ulcers After Roux-en-Y Gastric Bypass: Case Report
Daniel C Steinemann; Marc Schiesser; Pierre-Alain Clavien; Antonio Nocito
Authors and Disclosures
Posted: 03/28/2012; BMC Surg. 2011;11(33) © 2011 BioMed Central, Ltd.
Print This Email this
Abstract and Introduction
Background
Case Presentation
Discussion and Conclusion
References
Abstract and Introduction
Abstract
Background Anastomotic or marginal ulcers occur in 0.6 to 16% of patients after laparoscopic Roux-en-Y-Gastric Bypass. Initial therapy aims at eliminating known risk factors including smoking, Helicobacter pylori infection, use of non-steroidal anti-inflammatory drugs and inhibition of gastric acid secretion. While this approach is successful in 68 to 88% of the cases, up to one third of patients need a subsequent surgical revision. However, marginal ulcers still recur in up to 10% of cases after revisional surgery, thus constituting a serious challenge for bariatric surgeons.
Case presentation We herein report a case of an insidious marginal ulcer refractory to both medical therapy with high-dosed proton pump inhibitors and sucralfate as well as surgical therapy consisting of the lengthening of a short alimentary limb and later resection of the gastroenterostomy and construction of a new tension-free anastomosis. Only after gastrectomy by laparoscopic en-bloc resection of the gastrojejunostomy, the gastric pouch and resection of the gastric remnant with reconstruction by esophagojejunostomy the patient remained free of symptoms.
Conclusion By laparoscopic resection of the entire gastric pouch and the gastric remnant the risk to leave a suboptimally vascularised or even ischemic pouch in situ was avoided. The esophagojejunostomy was then created in healthy, good vascularised tissue. In our case this novel approach was effective in the management of a refractory anastomotic ulcer and might represent a rescue option when simple revision of the gastrojejunostomy fails.
Background
A specific complication after laparoscopic Roux-en-Y-Gastric-Bypass (LRYGB) is a marginal or anastomotic ulcer (AU) occurring at the gastrojejunal anastomosis. While AU can remain asymptomatic in 62-92% of the cases,[1–4] they can frequently cause disabling pain or complications such as perforation and bleeding.[5,6] The incidence of AU varies from 0.6% to 16% in endoscopic studies.[1–4]
The etiology of AU is unclear. Two classes of risk factors have been suggested: operative and patient related factors. Although large gastric pouch, vertically oriented pouch,[7] gastro-gastric fistula,[8] local tissue ischemia due to anastomotic tension[9] or presence of foreign bodies in the ulcer ground (e.g. nonabsorbable sutures)[10] have been previously discussed, there is still a lack of high level of evidence demonstrating these factors to be significant. In contrast, better data exist for patient related factors, showing that smoking (odds ratio (OR) 30.6), use of nonsteroidal anti-inflammatory drugs (OR 11.5) and lack of proton pump inhibitor (PPI) prophylaxis (OR 3) represent significant risk factors.[11]
Therefore, ulcer therapy starts with elimination of patient related risk factors and inhibition of gastric acid secretion. While this approach is successful in 68 to 88%, up to one third of the patients need a subsequent surgical revision.[8,12] Although revision surgery is successful in most cases, AU recur in up to 8%,[8] thus leading to a distressing situation for both patients and bariatric surgeons.
We herein report a case of an insidious AU refractory medical and surgical therapy, which finally required an aggressive approach consisting of laparoscopic gastric pouch and gastric remnant resection.
Discussion and Conclusion
Our case of a persistently recurring AU is representative for the current shortcomings in understanding the pathogenesis and thus optimal treatment of AU. We describe a successful approach for the management of intractable AU.
After LRYGB up to 7% of patients develop upper GI symptoms. Analysis and management of this condition is often challenging as 32% of symptomatic patients show a normal anatomy at endoscopy.[13] Conservative therapy has been reported to be successful in 68%-88% of the cases.[8,12] In our case, endoscopy showed no abnormalities apart from a short Roux limb at the time of referral. As a short Roux limb may facilitate biliary reflux causing postoperative pain and AU,[14] we decided to lengthen the alimentary limb. Despite improvement of regurgitation symptoms, epigastric pain and AU recurred.
Approximately one third of AU recur after medical therapy. For these cases a redo of the gastrojejunostomy with a success rate of 87% has been advised.[8] Before we embarked on this strategy, we reevaluated whether putative factors leading to a recurrence were present. Endoscopy and GI contrast series excluded potential operative risk factors. Therefore a resection of the gastrojejunostomy with subsequent PPI therapy was performed. However, the ulcer recurred potentially due to the inability of the patient to quit smoking.
After revision surgery for AU, a recurrence rate of 8% has been described. In these cases, revision of the gastrojejunostomy combined with gastric remnant resection has been advocated reducing gastrin-producing- and parietal cells.[8]
In contrast to the proposed simple revision of the anastomosis, we opted for a laparoscopic resection of the entire gastric pouch and the gastric remnant. By this means, the risk to leave a suboptimally vascularised or even ischemic pouch in situ was avoided since the resection was taken back to esophageal tissue. The circular esophagojejunostomy was then created in healthy, good vascularised tissue. Subsequently, the patient was free of symptoms and no recurrence was observed after a follow-up of 6 months. Hence, in our case this novel approach was effective in the management of a refractory AU and might represent a rescue option when simple revision of the gastrojejunostomy fails.