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.

Efficacy of the Glucagon-Like Peptide-1 Receptor Agonists Liraglutide and Semaglutide for the Treatment of Weight Regain After Bariatric surgery: a Retrospective Observational Study.

PURPOSE: Weight regain after bariatric surgery occurs in up to a third of patients and reduces treatment-associated health benefits. The efficacy of glucagon-like peptide-1 receptor agonists (GLP1-RA) for treatment of type 2 diabetes mellitus and obesity is well established, but their role in the treatment of weight regain after bariatric surgery remains to be defined. MATERIALS AND METHODS: This was a single centre retrospective observational study conducted at a Swiss bariatric reference centre. Patients with 6 months of treatment with GLP1-RA, up until November 2021, due to weight regain after bariatric surgery were identified. Data on body weight and relevant clinical parameters were collected before and after 6 months of treatment with GLP1-RA. Data are presented as median (interquartile range). RESULTS: Fifty patients (82% female) were included. Before GLP1-RA treatment (liraglutide, n=29; semaglutide, n=21), weight and BMI were 90.5 kg (83.4, 107.9) and 34.0 kg/m2 (31.7, 38.7), respectively, with a post-bariatric weight regain of 15.1% (10.6, 22.8) of total body weight and 4.6 kg/m2 (3.3, 6.2). After 6 months of GLP1-RA treatment, a reduction in weight and BMI of 8.8% (5.2, 11.4) of total body weight and 2.9 kg/m2 (1.8, 4.0) was observed (P value <0.0001), corresponding to 67.4% (40.4, 92.2) of the weight regain. No serious adverse events were reported. CONCLUSION: For patients experiencing weight regain after bariatric surgery, two-thirds of the weight regain can be safely lost with GLP1-RA, providing clinicians with a therapeutic option for this clinical challenge, and highlights the need for a large-scale randomized clinical trial.

C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity.

BACKGROUND: The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. METHODS: The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. RESULTS: Forty-nine of 410 patients (12.0 %; 95 % confidence intervals [95 % CI], 9.2-15.5 %) developed surgery-related complications. Leaks occurred in 17 patients (4.1 %; 95 % CI, 2.6-6.5 %) at a median of 5 days after surgery. CRP levels 2 days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95 % CI, 0.60-0.89). Sensitivity was 0.53 (95 % CI, 0.31-0.74) and specificity was 0.91 (95 % CI, 0.79-0.96) on day 2 (cutoff level, 229 mg/l). The sensitivity for intestinal leaks was 1.00 (95 % CI, 0.51-1.00). CONCLUSION: CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229 mg/l.