Apc a-00025-bile reflux gastritis and marginal ulcerPresentation Transcript
a-00025 Dr. Robert RUTLEDGETitle of Paper: BILE, REFLUX, GASTRITIS AND MARGINAL ULCER FOLLOWING BILLROTH II; MANAGEMENT OF DYSPEPSIA AFTER MINI-GASTRIC BYPASS Nationality: United States of America Position: Director Department: Surgery Organization: Center For Laparoscopic Obesity Surgery Tel: +1-702 714 0011
Marginal ulcer in jejunum after RNY. 3-cm ulcer (Long arrows) in proximal jejunum abutting G-J anastomosis (Small arrow). Narrow anastomosis, edema and spasm.Marginal Ulcer &Gastric Bypass
BILE, REFLUX, GASTRITIS AND MARGINAL ULCER FOLLOWING BILLROTH II; MANAGEMENT OFDYSPEPSIA AFTER MINI-GASTRIC BYPASS Robert RUTLEDGE11Director, Surgery, Center For Laparoscopic Obesity Surgery, United States of America
Epidemiology: What do we know about Marginal Ulcers?• “Marginal ulcers represent one of the most problematic postoperative complications following Roux-en-Y”• Reported “incidence of marginal ulcers is 0.6 to 16 %” in RNY Bypass
As Old as Abdominal Gastric Surgery• MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER SUBSEQUENT TO GASTROENTEROSTOMY.• Erdmann JF.• Ann Surg. 1921 Apr;73(4):434-40
Marginal Ulcer in RNY Gastric Bypass• 2,282 RNY Gastric Bypass• 122 (5%) Marginal ulcers• 39 (32%) Surgery• Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08536
Introduction• Dyspepsia post Mini-Gastric Bypass (MGB, Billroth II gastro-jejunostomy) may be• Erroneously labeled as "bile reflux."• Thousands of Billroth II (BII) patients have bile that flows harmlessly across their BII anastomosis every day.• In 6253 MGB patients, bile routinely flows across their BII with No symptoms.
Introduction• All patients with a Gastro-jejunostomy (GJ) have a well described risk of a variety of GI symptoms (i.e.: burning, nausea, vomiting, etc.)• For over 100 yrs General Surgeons have known that all forms of G-J anastomoses can develop Marginal Ulcer
Marginal Ulcer has been known since the beginning GI Surgery THE ROENTGEN DIAGNOSIS AND LOCALIZATION OF MARGINAL PEPTIC ULCER. Carman RD. Cal State J Med. 1920 Nov;18(11):377-82
Marginal Ulcer has been known since the beginning GI Surgery Re-evaluation of the role of the pyloric antrum in marginal peptic ulcers. SCHILLING JA, PEARSE HE. Surg Gynecol Obstet. 1948 Aug;87(2):225-34
Marginal Ulcer has been known since the beginning GI Surgery Vagotomy as a treatment for marginal ulcer. CRILE G Jr, BROWN GM Jr. Gastroenterology. 1951 Jan;17(1):14-9
Marginal Ulcer has been known since the beginning GI Surgery Review Article: The present status of the management of marginal ulcer. BYRD BF Jr. J Tn State Med Assoc. 1953 Feb;46(2):56-8.
Marginal Ulcer has been known since the beginning GI Surgery 2,282 RYGB 122 (5%) Marginal ulcers 39 (32%) Surgery Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08536
Marginal Ulcer Very High After RNY Gastric Bypass 441 RYGB 10 (12%) of RNY gastric bypass presented an "early" marginal ulcer Asymptomatic (28%) Obes Surg. 2009 Feb;19(2):135 Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Csendes A et al Department of Surgery, University Hospital, University of Chile, Santiago, Chile.
Dyspepsia after MGB• While it is possible that these patients can develop "bile reflux, "• The usual etiology of dyspepsia following BII• IS NOT BILE• but the more common of acid peptic disease (gastritis/ulcer.)
Think Three Pieces of Evidence• Marginal Ulcer in 100 years of G-J (BII and RNY)• Marginal Ulcer in RNY Gastric Bypass (No Bile)• Marginal Ulcer in MGB (+Bile)
Marginal Ulcer Rates• Marginal Ulcer in 100 years of G-J (BII and RNY)• (5%)• Marginal Ulcer in RNY Gastric Bypass (No Bile)• (5%)• Marginal Ulcer in MGB (+Bile)• (5%)
Results• Management Protocol: MGB patients suffering from dyspepsia symptoms, (symptoms that might easily be called "bile reflux")
Results• Medical treatment:• Rx H. Pylori,• PPIs/H2 Blockers,• +/- Carafate/Bismuth, other antacid treatment• Note: Never anti-Bile Rx
Results• In 6253 patients,• Followed for 15 years,• Dyspepsia (5%)• Medical treatment was effective in all but• 3 patients (Rx Braun Side to side Jejuno- jejunostomy (J-J).
Conclusions• The rising adoption of the MGB may lead to confusion when surgeons are faced with post operative BII patients.• Dyspepsia is relatively common after gastro-jejunostomy (BII = RNY).
Conclusions• In the vast majority of these cases the etiology is common acid peptic disease causing marginal gastritis/ulcer and is routinely responsive to medical treatment.• Failure of medical treatment is rare, but easily managed by brief laparoscopic Braun side to side J-J.
Confusion• Bile• Bile Reflux• Bile reflux Gastritis• Marginal Ulcer
Confusion• Bile; Everyone has Bile• Bile Reflux; BII has More Bile Reflux than others• Bile reflux Gastritis; Endoscopy of symptomatic Pts shows some gastritis in some patients (as in RNY pts)• Marginal Ulcer; Equal in RNY & MGB• Bile Makes No Difference