Marginal Ulcer after Gastric Bypass;
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Marginal Ulcer after Gastric Bypass;



Marginal Ulcer after Gastric Bypass; RNY & MGB ...

Marginal Ulcer after Gastric Bypass; RNY & MGB
Marginal ulcers RNY ranging from 0.6 to 16%
True incidence is very likely much higher
Csendes prospective study routine postoperative endoscopic evaluation
28% of marginal ulcers were asymptomatic
Gastric Bypass (RNY & MGB) HIGH incidence of Marginal Ulcer



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Marginal Ulcer after Gastric Bypass; Marginal Ulcer after Gastric Bypass; Presentation Transcript

  • First International ConsensusConference on the Mini-Bypass / One Anastomosis Bypass Paris 2012 October 18-19 Email DrR@CLOS.Net
  • Marginal Ulcer & Gastric Bypass
  • SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY1.  Low Risk2. Major Weight Loss3. Easily performed4. Short operative times5. Outpatient or short hospital stay6. Minimal Blood Loss7. No Need for ICU Stay8. Minimal Pain9. Very High Patient Satisfaction10. A Good "Exit Strategy" 
  • SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY11. Change Behavior & Preferences;  Marked Decrease in Hunger and Increased Satiety12. Minimal Retching and Vomiting 13. Few adhesions or hernias14. Minimal impact on Heart and Lung Function15. Low Failure Rate16. Low Cost17. Short Recovery Time18. Rapid Return to Work19. Low Risk of Pulmonary Embolus20. Durable weight loss
  • SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY21. Low Risk of Marginal Ulcer22. Fat Malabsorption; low cholesterol & CV risk 23. No Plastic Foreign Body 24. Easily Verifiable Results; > 10 years of Results25. Low Risk of Bowel Obstruction26. Based upon sound surgical principles  27. Independent confirmation of results28. Healthy life after surgery29. Supported by LEVEL I Evidence; RCT (Controlled Prospective Randomized Trial)30. Block “Sweet Eater” Failures
  • MINI-GASTRIC BYPASS•The Mini-Gastric Bypass1997 – 2011 ; >6,000 pts,10 yr Data; Multiple Centers,R.C.Trials•Vertical Gastric Tube(Collis Gastroplasty)•Gastric Bypass(Billroth II Gastro-jejunostomy)
  • MINI-GASTRIC BYPASSBASED SOUND SURGICAL PRACTICE •Billroth II Performed over 100 years•16,000 Billroth II’sUSA in 2007•Operation of choice: Trauma, Ulcers, Cancer Stomach etc.
  • Criteria for Success; Ideal Weight Loss Surgery RNY Band SG MGB1. Low Risk - + - +2. Major Weight Loss + - - ++3. Easily performed -- + + +4. Short operative times - + + +5. Short hospital stay -- + + +6. Minimal Blood Loss - + + +7. No Need for ICU Stay - + + +8. Minimal Pain - + + +9. High PatientSatisfaction - - - +10. A Good "Exit Strategy" - - - + -- +
  • Criteria for Success;Ideal Weight Loss Surgery RNY Band Sleeve MGB11. Decrease Hunger + - + +12. Min Vomiting + + + +13. No Internal hernias - + + +14. Min Heart/Lung - + + +15. Low Failure Rate - - - +16. Low Cost - - - +17. Short Recovery - + + +18. Return to Work - + + +19. Low Risk of PE - + + +20. Durable Weight Loss - - - +
  • Criteria for Success RNY Band SG MGB21. Low Risk of Ulcer - + + -22. Malabsorption of fat + - - +23. No Foreign Body + - + +24. Verifiable Results - - - ++25. Bowel Obstruction -- + + ++26. Sound Surgical + - + +27. Independent confirm - - - ++28. Healthy life - - - ++29. RCT; LEVEL I Evidence - - - ++30. Block Sweet Eater + - - ++
  • Epidemiology: What do we know aboutMarginal Ulcers?Marginal ulcers represent one of the most problematicpostoperative complications following Roux-en-YA marginal ulcer, or stomal ulceration, refers to thedevelopment of mucosal erosion at the gastrojejunalanastomosis, typically on the jejunal side.incidence of marginal ulcers is 0.6 to 16 %The true incidence is very likely much higher
  • Marginal Ulcer has been known since thebeginning GI SurgeryMARGINAL, GASTROJEJUNAL OR PEPTIC ULCERSUBSEQUENT TO GASTROENTEROSTOMY.Erdmann JF.Ann Surg. 1921 Apr;73(4):434-40. 
  • Marginal Ulcer has been known since thebeginning GI SurgeryTHE ROENTGEN DIAGNOSIS AND LOCALIZATIONOF MARGINAL PEPTIC ULCER.Carman RD.Cal State J Med. 1920 Nov;18(11):377-82
  • Marginal Ulcer has been known since thebeginning GI SurgeryRe-evaluation of the role of the pyloric antrum inmarginal peptic ulcers.SCHILLING JA, PEARSE HE.Surg Gynecol Obstet. 1948 Aug;87(2):225-34
  • Marginal Ulcer has been known since thebeginning 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 thebeginning GI SurgeryReview Article: The present status of the managementof marginal ulcer.BYRD BF Jr.J Tn State Med Assoc. 1953 Feb;46(2):56-8.
  • Marginal Ulcer has been known since thebeginning 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 ulcerafter Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, UniversityMedical Center at Princeton, Princeton, New Jersey 08536
  • Marginal Ulcer Very High After RNY GastricBypass 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.
  • Marginal Ulcer Very High After RNY GastricBypassAssociated with H. Pylori 260 RYGB 7% of RNY gastric bypass marginal ulcer H. pylori infection, (treated), was twice as common marginal ulceration (32%) as among those who did not (12%) Surg Endosc. 2007 Jul;21(7):1090-4. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Rasmussen JJ, Department of Surgery, University of California, Davis, 2221 Stockton Boulevard, Sacramento, CA 95817, USA
  • Marginal Ulcer after Gastric Bypass;Both RNY & MGBMarginal Ulcers after Roux-en-Y Gastric Bypass:Pain for the Patient…Pain for the Surgeonby Camellia Racu,January 2010Bariatric Times.2010;7(1):23–25
  • Marginal Ulcer after Gastric Bypass;RNY
  • Marginal Ulcer after Gastric Bypass;RNY & MGBMarginal ulcers RNY ranging from 0.6 to 16%True incidence is very likely much higherCsendes prospective studyroutine postoperative endoscopic evaluation28% of marginal ulcers were asymptomaticGastric Bypass (RNY & MGB)HIGH incidence of Marginal UlcerBILE MAKES NO DIFFERENCE!!!
  • Incidence of perforated gastrojejunalanastomotic ulcers after RNYApril 2002 to April 2010, 1213 patients underwentlaparoscopic RYGBOperative mortality was .15%10 perforated GJA ulcers (.82%) at a mean of 13.5(6-19) monthsMorbidity and mortality rate was 30% and 10%Perforated GJA ulcers can develop in 1 of 120 Rouxen Y Gastric Bypasses & DEADLY
  • Marginal Ulcers:Achilles Heel of Gastric BypassManagement1. Warn Patients & Surgeon “Be Vigilant”2. Aggressive anti-H. Pylori Rx3. Aggressive use of Antacids4. Strict Avoidance of Ulcerogenic Agents(NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates)5. Encourage: Probiotics, Yogurt, Fruits VegetablesBILE MAKES NO DIFFERENCE!!!
  • CONCLUSIONS:Best Choice: Mini-Gastric Bypass•Choice of Obesity Surgery•Objectives “Ideal” Weight Loss Surgery•RNY, Band, Sleeve, MGB•MGB Best meets all objectives/success criteria•Beware of Marginal Ulcer in RNY & MGB•Rational Decision Making:Best Choice; Mini-Gastric Bypass
  • Rational Data Analysis vs.Irrational FEAR Gastric Cancer•1. Gastric Cancer Declining Rapidly•2. GC Environmental Causes; Easily Prevented•3. Some studies show Small Increased Risk Probably from Ulcers / H. Pylori•4. Many large studies: NO increased risk•5. Endoscopic Screening: Not Recommended•6. General, Trauma & Oncologic Surgeons UseBillroth II