Marginal ulcers are a problematic complication following Roux-en-Y gastric bypass surgery, occurring in 0.6-16% of cases, with the true incidence likely being higher. Marginal ulcers, or stomal ulcers, develop at the gastrojejunal anastomosis and have been recognized since the earliest gastrointestinal surgeries in the 1920s. They occur at a very high rate of 12-28% following Roux-en-Y gastric bypass. Infection with H. pylori is associated with a doubled risk of marginal ulceration. Management involves warning patients, treating H. pylori, aggressive antacid use, and avoiding ulcerogenic agents.

1. Marginal Ulcer &
Gastric Bypass

8. Problem Definition:
Bariatric Surgery: A HISTORY OF FAILURE

9. The Gastric Sleeve:
Not as Bad as the Band
Not as Dangerous as the RNY

15. Criteria for Success;
Ideal Weight Loss Surgery

18. Epidemiology: What do we know about
Marginal Ulcers?
Marginal ulcers represent one of the most problematic
postoperative complications following Roux-en-Y
A marginal ulcer, or stomal ulceration, refers to the
development of mucosal erosion at the gastrojejunal
anastomosis, typically on the jejunal side.
incidence of marginal ulcers is 0.6 to 16 %
The true incidence is very likely much higher

19. Marginal Ulcer has been known since the
beginning GI Surgery
MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER
SUBSEQUENT TO GASTROENTEROSTOMY.
Erdmann JF.
Ann Surg. 1921 Apr;73(4):434-40.

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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.

26. Marginal Ulcer Very High After RNY Gastric
Bypass
Associated 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

27. 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

28. Marginal Ulcer after Gastric Bypass;
RNY

29. 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
BILE MAKES NO DIFFERENCE!!!

30. Incidence of perforated gastrojejunal
anastomotic ulcers after RNY
April 2002 to April 2010, 1213 patients underwent
laparoscopic 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 Roux
en Y Gastric Bypasses & DEADLY

31. 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!!!