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!!!

1. Marginal Ulcer &
Gastric Bypass
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.

3. Dr Rutledge: Training & Background
• Undergrad/Medical School; Teacher
Dr. Lester Dragstedt Pioneer / Inventor of the
Highly Controversial Vagotomy and Pyloroplasty
• 2 Years Cardiac Surgery National Institutes of Health National Heart Lun
• 20 years University of NC; Professor of Surgery, Associate Chief of Sta
• Author of 93 papers and articles

4. Dr Rutledge: Training & Background
• Specialty: Trauma, Critical Care, Medical Informatics and Bariatric Surgery (197
• Experience: Trauma Surgery, Director NC Trauma Registry
• Peptic Ulcer Surgery; Vagotomy & Pyloroplasty;
Antrectomy & Billroth II
• Bariatric Surgery 33 years:
Open RNY & Vertical Banded Gastroplasty
• 1997 one first surgeons laparoscopic RNY
• Mini-Gastric Bypass; 14 years, over 6,000 cases

5. Rutledge
14-0011 DrR@clos.net
RING THE MGB?
ERB SURGERY BUT…
ARNING:
TRICKS AND TRAPS”

6. E & SUCCESSFUL
PROGRAM
• Call / Email: Anytime question or advice on any clinical, technical or patie
• USA 001-702-714-0011 DrR@clos.net
• Personal Visit: Dr. Rutledge Visiting Professor: France, Turkey, Austria
Czech Republic, Italy, Germany, UAE, Pakistan,
• Please Use the Knowledge of Others Before You Start;
Experience; over 14 years, over 6,000 patients
• USA 001-702-714-0011 DrR@clos.net

7. HANDS ON” MGB IN INDIA
RAPS” TRAINING PROGRAM
• Didactic Sessions
Talk with the Leading World Experts
• Hands On Surgery (with approval)
Scrub in on cases
Assist and
Participate in MGB Surgery
• This Fall and Next Year
• Bija India, Dr Rutledge & Dr Kular
• USA 001-702-714-0011 DrR@clos.net

8. Problem Definition:
Bariatric Surgery: A HISTORY OF FAILURE
Procedure Assessment
Jejuno-ileal Bypass (Failure)
Vertical Banded Gastroplasty (Failure)
Lap Band (Fail?)
RNY Bypass (Fail?)
BPD/DS (Fail?)
Sleeve: 5% Leak, 60-80% GE Reflux, Irreversible,
Weight regain (Fail?)

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

10. 1. Low Risk
2. Major Weight Loss
3. Easily performed
4. Short operative times
5. Outpatient or short hospital stay
6. Minimal Blood Loss
7. No Need for ICU Stay
8. Minimal Pain
9. Very High Patient Satisfaction
10. A Good "Exit Strategy"
"IDEAL" WEIGHT LOSS SURGERY

11. "IDEAL" WEIGHT LOSS SURGERY
11. Change Behavior & Preferences; Marked Decrease in Hunger and Increa
12. Minimal Retching and Vomiting
13. Few adhesions or hernias
14. Minimal impact on Heart and Lung Function
15. Low Failure Rate
16. Low Cost
17. Short Recovery Time
18. Rapid Return to Work
19. Low Risk of Pulmonary Embolus
20. Durable weight loss

12. "IDEAL" WEIGHT LOSS SURGERY
21. Low Risk of Marginal Ulcer
22. Fat Malabsorption; low cholesterol & CV risk
23. No Plastic Foreign Body
24. Easily Verifiable Results; > 10 years of Results
25. Low Risk of Bowel Obstruction
26. Based upon sound surgical principles
27. Independent confirmation of results
28. Healthy life after surgery
29. Supported by LEVEL I Evidence; RCT (Controlled Prospective Randomize
30. Block “Sweet Eater” Failures

13. MINI-GASTRIC BYPASS
• The Mini-Gastric Bypass
1997 – 2011 ; >6,000 pts,
10 yr Data; Multiple Centers,
R.C.Trials
• Vertical Gastric Tube
(Collis Gastroplasty)
• Gastric Bypass
(Billroth II Gastro-jejunostomy)

14. BASED SOUND SURGICAL PRACTICE
• Billroth II Performed
over 100 years
• 16,000 Billroth II’s
USA in 2007
• Operation of choice: Trauma, Ulcers, Cancer Stomach etc.

15. Criteria for Success;
Ideal Weight Loss Surgery
RNY Band SG MGB
1. 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 Patient Satisfaction - - - +
10. A Good "Exit Strategy" - - - + - - +

16. Ideal Weight Loss Surgery
RNY Band Sleeve MGB
11. 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 - - - +

17. Criteria for Success
RNY Band SG MGB
21. 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 + - - ++

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

32. 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

34. • Why do Critics only care about the
Mini-Gastric Bypass?
• 100,000’s of people already have and are living with and are g
• Why haven’t concerned bariatric surgeons stepped forward to

35. • Why do Critics only care about the
Mini-Gastric Bypass?
• Why haven’t concerned bariatric surgeons stepped forward to s
to Roux-en-Y?
• Why don’t they write letters to the editor calling for the Billroth II

36. WHY CRITICS ONLY WORRY ABOUT THE M
• Why do Critics only care about the
Mini-Gastric Bypass?
• Why haven’t concerned bariatric surgeons stepped forward to
• It seems odd doesn’t it?
• There is a simple reason

37. WHY CRITICS ONLY WORRY ABOUT THE M
• There is a simple reason
• The critics of the MGB do not do those things because they ar
• Such actions are Not supported by the data
• The Billroth II and the MGB are both good operations
• Published data Does Not support the critics misreading of the

38. E EMBARRASSED

39. 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 Use Billroth II