Early marginal ulcer following Roux-en-Y gastric bypass under proton pump inhibitor treatment: prospective multicentric study

Abstract

-Context -Causal factors of gastrojejunal ulcers after Roux-en-Y gastric bypass include peptic acid secretion from the gastric pouch. Esomeprazole is a potent inhibitor of acid secretion. Objective -To assess the occurrence of dyspepsia and gastrojejunal ulcers within the first 2 months after Roux-en-Y gastric bypass during the use of esomeprazole. Methods -One hundred eighteen morbid obese subjects were submitted to Roux-en-Y gastric bypass. Preoperative upper gastrointestinal tract endoscopy was negative for H. pylori. All subjects received esomeprazole for 60 days after surgery. Results -Two weeks after surgery only 13 mild symptoms were reported. After 2 months, 17 also moderate complaints were registered. Endoscopy around the 60th day showed esophagitis in 10 (8.5%), hiatal hernia in 2 (1.7%), foreign body in the anastomotic line in 12 (10.2%) and gastrojejunal ulcers was observed in 9 (7.6%) subjects, 2 of which had a suture material or metallic staple granuloma in the gastrojejunostomy. Ten subjects took nonsteroidal anti-inflammatory drugs at least once during study, but none of them developed ulcer. None of the subjects with ulcer had dyspeptic symptoms. Conclusion -The incidence of ulcer in the gastrojejunal anastomosis within the first 2 months following Rouxen-Y gastric bypass under proton pump inhibitors is considerable. It was not related to the use of non-steroidal anti-inflammatory drugs, highlighting the possibility of ischemia and foreign body as causal factors. The ulcers were asymptomatic, and all post-surgical dyspeptic symptoms were moderate in severity.

Surgical Technique Affects the Incidence of Marginal Ulceration after Roux-en-Y in Gastric Bypass

“…This will affect the detection of MU. Several studies suggest MU is fairly frequent in the early postoperative period [25,26]. Only 24% of MU in the present study occurred early.…”

Two Important Criteria for Reducing the Risk of Postoperative Ulcers at the Gastrojejunostomy Site after Gastric Bypass: Patient Compliance and Type of Gastric Bypass

“…39 of 52 patients either smoked cigarettes or drunk alcohol or took NSAIDs. Although there are certain doubts regarding the destructiveness of these factors [21], the incidence in this study is quiet significant. Some authors discuss irreversible damage to the mucosal barrier due to H. pylori as a causal factor, even when the patient has been medically treated [15].…”

“…This suspicion is supported by our study, since 14 (27%) of 52 patients (p < 0.0001) suffered from stomal ulceration even after H. pylori had been eradicated. On the other hand, the most reviewed and ascertained pathognomonic factor for ulceration at the gastrojejunostomy site is local acidity [14,16,21] which is influenced by the interrelation of pouch size/form and acid production [14,21] and the existence of biliopancreatic reflux [23]. In this study, the B-II gastric bypass was created with a more tubular pouch.…”

“…Studies concerned with the gastric resection analogue Billroth II have already demonstrated the ulceration risk of that surgery and its association with acidity [17][18][19][20]. Understandably, common factors associated with stomal ulceration are pouch size, peptic acid production, pouch orientation, staple line integrity, mucosal ischemia, and suture material [14,16,21,22]. Other widely discussed risk factors, which are mostly regarded as contributors, are consumption of alcohol or nicotine, non-steroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori-associated gastritis in the preoperative course [14,15].…”

Stenosen und Ulzerationen nach bariatrischen Eingriffen

“…Es tritt im Bereich der GJ mit einer Inzidenz von 1-16 % auf [7]. Ulzerogene Perforationen oder Penetrationen sind von Fallberichten her bekannt.…”