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a-00025                   Dr. Robert RUTLEDGETitle of Paper: BILE, REFLUX, GASTRITIS AND MARGINAL   ULCER FOLLOWING BILLRO...
Marginal ulcer in jejunum after RNY. 3-cm ulcer (Long arrows) in proximal jejunum abutting G-J anastomosis (Small arrow). ...
BILE, REFLUX, GASTRITIS AND MARGINAL ULCER FOLLOWING BILLROTH II; MANAGEMENT OFDYSPEPSIA AFTER MINI-GASTRIC           BYPA...
Epidemiology: What do we know      about Marginal Ulcers?• “Marginal ulcers represent one of the  most problematic postope...
As Old as     Abdominal Gastric Surgery• MARGINAL, GASTROJEJUNAL OR  PEPTIC ULCER SUBSEQUENT TO  GASTROENTEROSTOMY.• Erdma...
Marginal Ulcer in RNY Gastric Bypass• 2,282 RNY Gastric Bypass• 122 (5%) Marginal ulcers• 39 (32%) Surgery• Surg Obes Rela...
Introduction• Dyspepsia post Mini-Gastric Bypass  (MGB, Billroth II gastro-jejunostomy) may  be• Erroneously labeled as "b...
Introduction• All patients with a Gastro-jejunostomy  (GJ) have a well described risk of a  variety of GI symptoms (i.e.: ...
Marginal Ulcer has been known since the          beginning GI Surgery THE ROENTGEN DIAGNOSIS AND LOCALIZATION  OF MARGINA...
Marginal Ulcer has been known since the          beginning GI Surgery Re-evaluation of the role of the pyloric antrum in ...
Marginal Ulcer has been known since the          beginning GI Surgery Vagotomy as a treatment for marginal ulcer. CRILE ...
Marginal Ulcer has been known since the          beginning GI Surgery Review Article: The present status of the  manageme...
Marginal Ulcer has been known since the             beginning GI Surgery 2,282 RYGB 122 (5%) Marginal ulcers 39 (32%) S...
Marginal Ulcer Very High After                 RNY Gastric Bypass 441 RYGB 10 (12%) of RNY gastric bypass presented an "...
Dyspepsia after MGB• While it is possible that these patients  can develop "bile reflux, "• The usual etiology of dyspepsi...
Think Three Pieces of Evidence• Marginal Ulcer in 100 years of G-J (BII  and RNY)• Marginal Ulcer in RNY Gastric Bypass  (...
Marginal Ulcer Rates• Marginal Ulcer in 100 years of G-J (BII  and RNY)• (5%)• Marginal Ulcer in RNY Gastric Bypass       ...
Results• Management Protocol: MGB patients  suffering from dyspepsia symptoms,  (symptoms that might easily be called  "bi...
Results• History:  ?Daily Yogurt (protective);  Alcohol/processed meats/"junk foods, "  NSAIDS, Smoking (“Ulcerogenic”), L...
Results• Medical treatment:• Rx H. Pylori,• PPIs/H2 Blockers,• +/- Carafate/Bismuth, other antacid  treatment• Note: Never...
Results• In 6253 patients,• Followed for 15 years,• Dyspepsia (5%)• Medical treatment was effective in all  but• 3 patient...
Conclusions• The rising adoption of the MGB may  lead to confusion when surgeons are  faced with post operative BII patien...
Conclusions• In the vast majority of these cases the  etiology is common acid peptic disease  causing marginal gastritis/u...
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 o...
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Apc a-00025-bile reflux gastritis and marginal ulcer

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Apc a-00025-bile reflux gastritis and marginal ulcer

  1. 1. 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
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. As Old as Abdominal Gastric Surgery• MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER SUBSEQUENT TO GASTROENTEROSTOMY.• Erdmann JF.• Ann Surg. 1921 Apr;73(4):434-40
  6. 6. 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
  7. 7. 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.
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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.
  13. 13. 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
  14. 14. 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.
  15. 15. 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.)
  16. 16. 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)
  17. 17. 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%)
  18. 18. Results• Management Protocol: MGB patients suffering from dyspepsia symptoms, (symptoms that might easily be called "bile reflux")
  19. 19. Results• History: ?Daily Yogurt (protective); Alcohol/processed meats/"junk foods, " NSAIDS, Smoking (“Ulcerogenic”), Labs: H. Pylori, Hgb Fe LFT, s etc.• Recommend: Yogurt (plain) daily + probiotics, AVOID: alcohol, cigarettes, tobacco, NSAIDs
  20. 20. Results• Medical treatment:• Rx H. Pylori,• PPIs/H2 Blockers,• +/- Carafate/Bismuth, other antacid treatment• Note: Never anti-Bile Rx
  21. 21. 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).
  22. 22. 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).
  23. 23. 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.
  24. 24. Confusion• Bile• Bile Reflux• Bile reflux Gastritis• Marginal Ulcer
  25. 25. 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

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