Laparoscopic Management of Gastrocolic Fistula in a Patient with a History of an Unusual Loop Gastric Bypass-a Video Vignette.

Gastrocolic fistula (GCF) is defined as an abnormal pathological communication between the epithelialized mucosal layers of the stomach and colon. In rare cases, complications following gastric bypass surgery, such as leakage or complicated marginal ulcers, may contribute to the development of a GCF. The laparoscopic approach for managing GCF involves a one-stage procedure that includes resection of the fistula and reconstruction of the gastrointestinal tract.

Early marginal ulceration prevalence following primary RYGB: a rare events model of the MBSAQIP 2015-2021.

PURPOSE: Marginal ulceration (MU) following Roux-en-Y gastric bypass (RYGB) is an established complication, with early MU (within 30-days of operation) being less understood compared to its late counterpart. This study aims to identify risk factors for early MU in patients undergoing primary RYGB. METHODS: Utilizing data from the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP 2015-2021), 1,346,468 records were evaluated. After exclusions for revisions, conversions, pediatric cases, nonbinary gender, missing body mass index (BMI) data, and missing operative time; 291,625 cases of primary RYGB were included for full analysis and rare events modeling of early MU. RESULTS: The prevalence of early MU was .29% (n = 850). Higher rates of early MU were associated with BMI, race, history of diabetes mellitus (DM), prior thrombotic complications (deep vein thrombosis (DVT) and pulmonary embolism (PE)), prior percutaneous cardiac intervention (PTC), immunosuppressive therapy, and anticoagulation status. Additionally, procedural aspects like the nonspecialization of the surgeon and longer operative times also correlated with higher early MU rates. Rare-events regression modeling noted significant associations of early MU with younger age, diabetes requiring insulin, history of PTC, DVT, immunosuppressive therapy, and anticoagulation status. CONCLUSION: Early MU remains a relatively rare complication. The lower than previously reported occurrence suggests possible improvements in both patient preparation and surgical technique. The identification of relevant risk factors enables better perioperative and intraoperative management of patients at risk of developing early MU.

Case report: Concurrent intussusception and bleeding marginal ulcer in a patient with gastric bypass.

INTRODUCTION: The source of abdominal pain in patients with a history of gastric bypass can be difficult to determine. Synchronous disease processes may ultimately be the cause of their symptoms. Among the etiologies for hematemesis and obstruction in this population are the diagnoses of marginal ulcer and internal hernia. Given the potential complications of bariatric surgery, it is important to maintain a broad differential diagnosis during the workup of these patients. PRESENTATION: A female with history of laparoscopic Roux-en-Y gastric bypass (RYGB) presented with abdominal pain and hematemesis. Intraoperative findings revealed intussusception of the jejunojejunostomy resulting in obstruction and ischemic bowel. Additionally, a perforated marginal ulcer of the Roux-limb was found to be present. This patient underwent esophagogastroduodenoscopy, bowel resection, jejunojejunostomy revision, and Graham patch repair. DISCUSSION: This case highlights a patient with history of RYGB presenting with obstruction and gastrointestinal bleeding. Although initially diagnosed with internal hernia and Mallory-Weiss hematemesis, surgical exploration revealed concurrent intussusception and marginal ulceration. While intussusception is a rare complication of bariatric surgery, it can occur secondary to mesenteric thinning and motility dysfunction from significant weight loss. It is imperative to maintain a broad differential diagnosis for the causes of obstruction and GI bleeding that include adhesive disease, abdominal wall hernia, internal hernia, intussusception, and marginal ulcers. CONCLUSION: Findings of obstruction or GI bleeding after bariatric surgery may represent a surgical emergency. While these symptoms may be attributed to a single diagnosis, clinicians must consider the presence of synchronous pathologies during the workup of patients.

Upper gastrointestinal endoscopy in the surgically altered patient.

As management of upper gastrointestinal malignancies improves, and with popularization of bariatric surgery, endoscopists are likely to meet patients with altered upper gastrointestinal anatomy. Short-term, the surgery can cause complications like bleeding, leaks, and fistulas, and longer-term problems such as intestinal or biliary anastomotic strictures or biliary stones can arise, all necessitating endoscopy. In addition, the usual upper gastrointestinal pathologies can also still occur. These patients pose unique challenges. To proceed, understanding the new layout of the upper gastrointestinal tract is essential. The endoscopist, armed with a clear plan for navigation, can readily diagnose and manage most commonly occurring conditions, such as marginal ulcers and proximal anastomotic strictures with standard endoscopic instruments. With complex reconstructions involving long segments of small bowel, such as Roux-en-Y gastric bypass, utilization of balloon-assisted enteroscopy may be necessary, mandating modification of procedures such as endoscopic retrograde cholangiopancreatography. Successful endoscopic management of patients with altered anatomy will require prior planning and preparation to ensure the appropriate equipment, setting, and skill set is provided.

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 marginal ulcer perforation after Roux-en-Y Gastric bypass - A case report with two-step management.

INTRODUCTION: Marginal ulcers are an acid-related complication of laparoscopic Roux-en-Y gastric bypass. Few cases of acute perforation have been described, and there are few reports on viable surgical management. This case report demonstrates a two-step surgical procedure for treating a perforated late marginal ulcer in a patient with sepsis. PRESENTATION OF CASE: A 39-year-old smoker presented to the emergency department six years after undergoing a Roux-en-Y gastric bypass. Diagnostic findings revealed ascites and changes in intestinal calibre, indicating the need for surgery. Intraoperatively, a perforated marginal ulcer covered by the liver was observed. Given the extent of the perforation and the patient's increased instability, discontinuity resection was performed. After stabilisation and improvement in the nutritional status, the gastrojejunostomy was restored nine weeks later. DISCUSSION: Treatment of Marginal ulcers is controversial, with no clear guidelines. However, severe complications require endoscopic or surgical treatment. The literature considers three main surgical treatment options for perforated marginal ulcers: surgical repair, surgical anastomotic revision, and gastric bypass reversal. Complicated situations, significant intraoperative findings, and unstable patients require tailored approaches. CONCLUSION: A two-step procedure with discontinuity resection for damage control surgery, patient stabilisation, and improvement of nutritional status, followed by elective continuity restoration with a new gastrojejunostomy, is considered feasible in critically ill patients.

Similar Rates of Symptomatic Marginal Ulcers After One-Anastomosis-Gastric Bypass Compared to Roux-en-Y Gastric Bypass.

PURPOSE: One-anastomosis-gastric-bypass (OAGB) has become a common bariatric procedure worldwide. Marginal ulcers (MU) are a significant non-immediate complication of gastric bypass surgeries. There seems to be concern among surgeons that MU are more common after OAGB compared with Roux-en-Y gastric bypass (RYGB) due to the constant and extensive exposure of the anastomosis to bile. The aim of this study was to compare the incidence, presentation, and management of MU between the two surgeries. MATERIALS AND METHODS: A retrospective study of prospectively collected data was performed to include all consecutive patients between 2010 and 2020, who underwent elective OAGB or RYGB at our institution. Patients diagnosed with symptomatic MU were identified. Factors associated with this complication were assessed and compared between the two surgeries. RESULTS: Symptomatic MU were identified in 23/372 OAGB patients (6.2%) and 35/491 RYGB patients (7.1%) (p = 0.58). Time to ulcer diagnosis was shorter in OAGB patients (12 ± 11 vs. 22 ± 17 months, p < 0.01). Epigastric pain was the common symptom (78% OAGB vs. 88.5% RYGB, p = 0.7) and approximately 15% of ulcers presented with perforation upon admission (17% vs.11.4%, p = 0.7). Re-operation was required in 5/23 OAGB (21.7%) and 6/36 RYGB (17%) patients (p = 0.11) while the rest of the patients were managed non-operatively. CONCLUSIONS: The risk of developing a marginal ulcer is similar between patients who underwent OAGB and RYGB. Patients diagnosed with MU following OAGB tend to present earlier; however, the clinical presentation is similar to RYGB patients. The management of this serious complication seems to be associated with acceptable outcomes with comparable operative and non-operative approaches.

Early Marginal Ulcer After Roux-en-Y Gastric Bypass: MBSAQIP Database Analysis of Trends and Predictive Factors.

PURPOSE: Marginal ulcer (MU) is a known complication after Roux-en-Y gastric bypass (RYGB) that carries significant morbidity. First, we aimed to determine the trends and the rates of readmission, reintervention, and reoperation of 30-day MU. Second, we aim to determine the predictive factors associated with this complication. MATERIALS AND METHODS: Patients who had 30-day marginal ulcer (MU) after LRYGB were identified using the 2015-2021 MBSAQIP database. Those who had a 30-day complication other than MU were excluded. Bivariate and logistic regression analyses were performed. RESULTS: Among 213,104 patients undergoing laparoscopic RYGB, 638 (0.3%) showed 30-day MU. This group of patients required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Predictive factors for 30-day MU after RYGB were renal insufficiency, history of DVT, previous cardiac stent, African American race, chronic steroid use, COPD, therapeutic anticoagulation, anastomotic leak test, GERD, and operative time > 120 min. Additionally, patients who had 30-day MU showed significantly higher rates of overall complications such as pulmonary, cardiac and renal complications, unplanned ICU admission, blood transfusions, venous thromboembolism (VTE), and non-home discharge (p < 0.05). The MU group showed similar rates of 30-day mortality as those without this complication (0.2% vs 0.1%, p = 0.587). CONCLUSIONS: The incidence of 30-day MU following RYGB was 0.3%. Patients with MU required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Some preoperative and intraoperative factors contributed to an increased risk of 30-day MU.

The incidence and risk factors of marginal ulcers in the short and medium term in symptomatic post-pancreaticoduodenectomy patients ---- single-center experience.

BACKGROUND: Marginal ulcer (MU) is one of the postoperative complications of pancreaticoduodenectomy (PD), which needs particular attention in postoperative treatments. METHODS: The data of 190 patients who underwent PD and follow-up gastroscopic review due to upper GI symptoms within two years were retrospectively analyzed. The incidence of MU and risk factors were analyzed based on personal history, surgical procedure, past medical history, postoperative complications, and other relevant indicators. RESULTS: The proportion of MU in patients who underwent endoscopic follow-up for upper gastrointestinal symptoms in the postoperative period in this cohort was 10.5% (20/190). Advanced age (69y vs. 59y, P â€‹= â€‹0.012), alcohol consumption (20% vs. 8.2%, P â€‹= â€‹0.03), and cigarette smoking (35% vs. 14.7%, P â€‹= â€‹0.022) were associated with an increased incidence of MU. Longer surgery time (276.5min vs. 240min, P â€‹= â€‹0.049), postoperative bleeding (10% vs. 1.8%, P â€‹= â€‹0.030), and failure to take antacid regularly postoperatively (75% vs. 97.1%, P â€‹= â€‹0.000) would increase the risk of MU; taking antacid regularly was an independent protective factor for postoperative anastomotic ulceration (OR: 0.091, CI: 0.022-0.383, P â€‹= â€‹0.001). CONCLUSION: Advanced age, alcohol consumption, smoking, longer operation time, or postoperative extraluminal hemorrhage are associated with MU. Regular use of antacids is an independent protective factor against the development of MU.

Marginal Ulcer Incidence and the Population of Gastrin Producing G cells Retained in the Gastric Pouch after Roux-en-Y Gastric Bypass: Is There a Relationship?

INTRODUCTION: Marginal ulcers are the most prevalent endoscopic abnormality after RYGB. The etiology is still poorly understood; however, an increase in acid secretion has been strongly implicated as a causal agent. Although gastrin is the greatest stimulant of acid secretion, to date, the presence of gastrin producing G cells retained in the gastric pouch, related to the occurrence of marginal ulcers, has not been evaluated. OBJECTIVE: Evaluate the density of G cells and parietal cells in the gastric pouch of RYGB patients with a diagnosis of marginal ulcer on the post-op EGD. METHOD: We retrospectively evaluated 1104 gastric bypasses performed between 2010 and 2020. Patients with marginal ulcer who met the inclusion criteria and controls were selected from this same population. Endoscopic gastric pouch biopsies were evaluated using immunohistochemical study and HE staining to assess G cell and parietal cell density. RESULTS: In total, 572 (51.8%) of the patients performed endoscopic follow-up after RYGB. The incidence of marginal ulcer was 23/572 (4%), and 3 patients required revision surgery due to a recalcitrant ulcer. The mean time for ulcer identification was 24.3 months (2-62). G cell count per high-power field (× 400) was statistically higher in the ulcer group (p < 0.05). There was no statistical difference in parietal cell density between groups (p 0.251). CONCLUSION: Patients with a marginal ulcer after gastric bypass present a higher density of gastrin-producing G cells retained in the gastric pouch.

Is open-capsule proton pump inhibitor associated with faster healing time for marginal ulceration after Roux-en-Y gastric bypass?

BACKGROUND: Marginal ulceration (MU) is a significant cause of morbidity after Roux-en-Y gastric bypass (RYGB). Proton pump inhibitors (PPIs) are the primary treatment. Prior limited data suggest that open-capsule PPIs (OC-PPIs) improve MU healing compared with intact-capsule PPIs (IC-PPIs), necessitating further validation. OBJECTIVES: We aimed to compare healing times of MU after RYGB when treated with OC-PPIs versus IC-PPIs. SETTING: Tertiary academic center, United States. METHODS: We retrospectively analyzed patients with prior RYGB diagnosed with MU from 2012 to 2022. Patients requiring mechanical closure without documented healing and without clear PPI prescriptions were excluded. The primary outcome was time to ulcer healing. Log-rank testing and Kaplan-Meier survival curve analyses were performed to compare MU healing times when treated with OC-PPIs versus IC-PPIs. Subgroup analyses further characterized ulcer healing times based on type and dosage of PPI used. RESULTS: A total of 108 patients were included for final analysis (38 received OC-PPIs and 70 received IC-PPIs). Treatment with OC-PPIs significantly decreased MU healing time compared with IC-PPIs (146.18 versus 226.14 d; p = .018). However, when stratified by PPI potency, the positive effect of opening the capsule lost significance. CONCLUSION: In this study, OC-PPIs significantly improved MU healing times compared with IC-PPIs in RYGB patients, consistent with prior data. However, on subgroup analysis comparing therapy with similar PPI potency, the MU healing time did not differ with respect to administration method. These results highlight the need for a prospective randomized trial to compare the true effect of administration method.

Bariatric Surgery Emergencies in Acute Care Surgery.

Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.

Does One-Anastomosis Gastric Bypass Expose Patients to Gastroesophageal Reflux: a Systematic Review and Meta-analysis.

This systematic review and meta-analysis aimed to investigate the incidence of new-onset gastroesophageal reflux, reflux change, esophagitis, Barrett's esophagus, and revision due to reflux, gastritis, and marginal ulcer after one-anastomosis gastric bypass (OAGB). We performed subgroup analyses based on primary and revisional OAGB and time of follow-up. Meta-analysis of 87 studies with 27,775 patients showed a 6% rate of new-onset reflux after OAGB. Preoperative reflux status did not change significantly after OAGB. The rate of esophagitis and Barrett's esophagus was 15% and 1%, respectively. The new-onset reflux rate after OAGB was significantly higher than gastric bypass but not different with sleeve gastrectomy. The current study showed a relatively low rate of reflux and its complications after OAGB, but it was significantly higher than Roux-en-Y gastric bypass.

Operative technique for a successful laparoscopic en-bloc resection of gastrogastric fistula following roux-en-Y gastric bypass.

Gastrogastric fistulas are rare complications following Roux-en-Y gastric bypass surgery and are characterized by a fistulous connection between the gastric pouch and the remnant stomach. The presentation is often variable and a high-index of suspicion must be maintained for accurate and timely diagnosis. In this case report, we provide a detailed review of the technical steps taken to successfully resect a gastrogastric fistula en-bloc laparoscopically with an unremarkable post-operative course.

Marginal Ulcer and Dumping Syndrome in Patients after Duodenal Switch: A Multi-Centered Study.

BACKGROUND: The current design of biliopancreatic diversion with duodenal switch (BPD/DS) and single anastomosis duodenal-ileal bypass with sleeve (SADI-S) emphasizes the importance of the pylorus' preservation to reduce the incidence of marginal ulcer (MU) and dumping. However, no institutional studies have yet reported data on their prevalence. We aimed to assess the incidence of MU and dumping after duodenal switch (DS) and identify the associative factors. METHODS: A multi-center review of patients who underwent BPD/DS or SADI-S between 2008 and 2022. Baseline demographics, symptoms, and management of both complications were collected. Fisher's exact test was used for categorical variables and the independent t-test for continuous variables. RESULTS: A total of 919 patients were included (74.6% female; age 42.5 years; BMI 54.6 kg/m2) with mean follow-up of 31.5 months. Eight patients (0.9%) developed MU and seven (0.8%) had dumping. Patients who developed MU were more likely to be using non-steroidal anti-inflammatory drugs (NSAID) (p = 0.006) and have a longer operation time (p = 0.047). Primary versus revisional surgery, and BDP/DS versus SADI-S were not associated with MU or dumping. CONCLUSIONS: The incidences of MU and dumping after DS were low. NSAID use and a longer operation time were associated with an increased risk of MU, whereas dumping was attributed to poor dietary habits.

Repair of a Perforated Marginal Ulcer Seven Years After Roux-en Y Gastric Bypass: A Case Report and Review of Literature.

Marginal ulcers can be a rare but fatal post-surgical complication of Roux-en-Y gastric bypass (RYGB). In this report, we will describe the case of a 70-year-old female, with a seven-year status post-gastrojejunostomy who presented with a perforated marginal ulcer and showed significant improvement in her symptoms after a revisional operation for the marginal ulcer. The goal of this case report is to make clinicians aware of the unique complications of RYGB and outline the appropriate workup for patients presenting with post-bariatric abdominal pain.

Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management.

Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.

Perforated Marginal Ulcer.

Marginal ulcers are a late complication of gastric bypass surgery. A marginal ulcer is a term for ulcers that develop at the margins of a gastrojejunostomy, primarily on the jejunal side. A perforated ulcer involves the entire thickness of an organ, creating an opening on both surfaces. We will present an intriguing case of a 59-year-old Caucasian female who arrived at the emergency department with diffused chest and abdominal pain that began in her left shoulder and went down to the right lower quadrant area. The patient was in visible pain with restlessness, and her abdomen was moderately distended. The computed tomography (CT) showed possible perforation in the gastric bypass surgery area, but the results were inconclusive. The patient had laparoscopic cholecystectomy ten days prior, and the pain began right after surgery. The patient underwent an open abdominal exploratory surgery, with the closure of the perforated marginal ulcer. The fact that the patient had undergone another surgery and had pain immediately afterward also obscured the diagnosis. This case shows the rare presentation of the patientäs diverse signs and symptoms and inconclusive reports that led to the open abdominal exploratory surgery that finally confirmed the diagnosis. This case highlights the importance of a thorough past medical history, including surgical history. The past surgical history led the team to zone in on the gastric bypass area, leading to an accurate differential diagnosis.

Rates of Recurrent Marginal Ulcer in Gastric Bypass Patients Undergoing Revisional Surgery.

INTRODUCTION: The rate of marginal ulcer (MU) following primary Roux-en-Y Gastric Bypass (RYGB) is approximately .6-16%. Few studies have evaluated recurrence rates following surgical revision for MU. The primary aim of this study was to determine the rate of MU recurrence following revision. The secondary aim was to evaluate the impact of truncal vagotomy (TV) on the recurrence rates and analyze potential risk factors associated with the recurrence of MU after revision. METHODS: We conducted a retrospective cohort study examining data at a single tertiary academic medical center. Adult patients with a history of RYGB who underwent gastrojejunostomy revision for recurrent MU between the years of 2003-2020 were included. We sought to determine our overall rate of MU following revision, with and without TV. Additionally, we examined the association of risk factors with MU recurrence. Fisher's exact test was used to determine the statistical significance of recurrence rates between the groups. RESULTS: We included 90 patients in the study. The overall recurrence rate for MU was 16.7%. Of the 90 patients, 35 (35.4%) patients underwent TV at the time of revision. The recurrence rate of MU after GJ revision with TV was 14.3% in comparison to those without TV, 18.2% (P = .775). Smoking, steroid, alcohol use, history of cardiac surgery/intervention, and helicobacter pylori were not significantly associated with recurrent MU following revision. CONCLUSIONS: The rate of recurrence after revision for MU is high. Adding TV trended towards decreased MU recurrence after revisional surgery, however not significant. Larger studies are needed to evaluate risk factors associated with recurrent MU after revision.