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Surgery For Obesity and Related... Sep 2022Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal... (Review)
Review
Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal ulcers. We performed a systematic review to understand the presentation, management, and outcomes of PMUs. PubMed, Google Scholar, and Embase databases were searched to identify all studies on PMUs after gastric bypass procedures. A total of 610 patients were identified from 26 articles. The mean age was 39.8±2.59 years, and females represented most of the cohort (67%). The mean body mass index was 43.2±5.67 kg/m. Most of the patients had undergone a Roux-en-Y gastric bypass (98%). The time gap between the primary bariatric surgery and the diagnosis of PMU was 27.5±8.56 months. The most common presenting symptom was abdominal pain (99.5%) and a computed tomography scan was the diagnostic modality used in 72% of the patients. Only 15% of patients were on prophylactic proton pump inhibitors or H2 blockers at the time of perforation, and 41% of patients were smoking at the time. Twenty-three percent of patients were on nonsteroidal anti-inflammatory drugs. Laparoscopic omental patch repair of the perforation (59%) was the most used technique; 18% of patients underwent open surgery, and 20% were managed non-surgically. Thirty-day mortality was 0.97%; it was 1.21% (n=5) and 0% (n=0) in those who were managed surgically and nonsurgically, respectively. Ulcers recurred in 5% of patients. In conclusion, PMU is a surgical emergency after gastric bypass that can result in significant morbidity and even mortality. This is the first systematic review in scientific literature characterizing this condition.
Topics: Adult; Female; Gastric Bypass; Humans; Laparoscopy; Obesity; Obesity, Morbid; Peptic Ulcer; Retrospective Studies; Ulcer
PubMed: 35810084
DOI: 10.1016/j.soard.2022.05.024 -
Surgery Jul 2020Marginal ulcer is a well-known complication after pancreatoduodenectomy. In light of increasing long-term survival after pancreatoduodenectomy, the identification of...
BACKGROUND
Marginal ulcer is a well-known complication after pancreatoduodenectomy. In light of increasing long-term survival after pancreatoduodenectomy, the identification of risk factors and preventive strategies are of utmost importance. We assessed the incidence, clinical impact, and potential risk factors of marginal ulcer after pancreatoduodenectomy.
METHODS
A prospectively maintained database of patients undergoing pancreatoduodenectomy was analyzed retrospectively. Univariate and bivariate competing-risk Cox regression analyses were performed to identify risk factors for marginal ulcer.
RESULTS
Two hundred and fifty-five consecutive patients underwent pancreatoduodenectomy. The median follow-up was 35.7 months. Marginal ulcer was diagnosed in 19 patients (7.5%), and the median time from pancreatoduodenectomy to marginal ulcer diagnosis was 450 days. Thirteen of these 19 patients presented with abdominal pain, melena, or anemia. In all these 13 patients, marginal ulcer resolved with proton pump inhibitor therapy and endoscopic surveillance. Six patients with marginal ulcer presented with an acute abdomen and underwent emergency laparotomy for marginal ulcer perforation and peritonitis. There was no marginal ulcer-related mortality. Univariate and bivariate competing-risk analyses showed an increased risk for marginal ulcer with discontinuation of proton pump inhibitor therapy, smoking, alcohol intake, and the use of non-steroidal anti-inflammatory drugs. Discontinuation of proton pump inhibitor therapy was an independent risk factor for marginal ulcer development.
CONCLUSION
Marginal ulcer is a relevant long-term complication after pancreatoduodenectomy that occurs more frequently after proton pump inhibitor therapy is discontinued. Based on our data, permanent use of proton pump inhibitor after pancreatoduodenectomy is strongly recommended especially for those patients who smoke, consume alcohol, or use non-steroidal anti-inflammatory drugs.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Female; Germany; Humans; Male; Middle Aged; Pancreaticoduodenectomy; Peptic Ulcer; Postoperative Complications; Proton Pump Inhibitors; Retrospective Studies; Young Adult
PubMed: 32276736
DOI: 10.1016/j.surg.2020.02.012 -
Current Problems in Surgery Feb 2020
Review
Topics: Humans; Incidence; Peptic Ulcer; Peptic Ulcer Perforation; Prevalence
PubMed: 32138833
DOI: 10.1016/j.cpsurg.2019.100728 -
Obesity Surgery Dec 2020Marginal ulcer is one of the most common complications after Roux-en-Y gastric bypass and is defined as an ulceration of any depth at or near the gastrojejunal...
INTRODUCTION
Marginal ulcer is one of the most common complications after Roux-en-Y gastric bypass and is defined as an ulceration of any depth at or near the gastrojejunal anastomosis. Different risk factors have been advocated to be the causative agent.
MATERIALS AND METHODS
The weighted discharges from the Nationwide Inpatient Sample from 2003 to 2011 were used to assess for risk factors to develop marginal ulcer such as Helicobacter pylori infection, chronic nonsteroidal anti-inflammatory use, chronic aspirin use, alcohol dependence, smoking, hypertension, and diabetes mellitus type II.
RESULTS
Chronic nonsteroidal anti-inflammatory drug use was the most significant risk factor for marginal ulcer, followed by Helicobacter pylori infection, obstructive sleep apnea, female sex, smoking, and alcohol dependence in decreasing order. Diabetes mellitus and hypertension were found to slightly increase the risk for marginal ulcer. The use of aspirin was found to be a minor risk factor during univariate analysis but a protective factor during multivariate analysis.
CONCLUSIONS
Multiple well-documented single factors are related to the genesis of a marginal ulcer, although it is likely that a combination of risk factors is responsible for this problem. These risk factors should be identified and removed or controlled.
Topics: Female; Gastric Bypass; Helicobacter Infections; Helicobacter pylori; Humans; Male; Obesity; Obesity, Morbid; Peptic Ulcer; Risk Factors; Stomach Ulcer
PubMed: 32939660
DOI: 10.1007/s11695-020-04960-z -
The American Surgeon Dec 2023Marginal ulcers, defined as ulcers at the duodenojejunostomy or gastrojejunostomy, are a known late-onset complication of pancreaticoduodenectomy (PD) and total...
Marginal ulcers, defined as ulcers at the duodenojejunostomy or gastrojejunostomy, are a known late-onset complication of pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with mean incidence ranging from 5.4% to 36% per the literature. These ulcers carry a risk of complications including hemorrhage or perforation which can result in significant mortality. Marginal ulcers from PD and TP causing portal vein erosion are extremely rare and given the high incidence of mortality, it is important to have a multimodal approach to the treatment with awareness that early operative management should be considered if other modalities fail. We discuss the case of a 57-year-old female with history of pancreatic tail intraductal papillary mucinous neoplasm (IPMN) status post distal pancreatectomy/splenectomy and subsequent completion pancreatectomy for pancreatic head IPMN who presented with acute gastrointestinal bleed. The patient was successfully managed operatively with primary repair of the marginal ulcer after multiple failed endoscopic attempts.
Topics: Female; Humans; Middle Aged; Pancreatectomy; Pancreatic Neoplasms; Carcinoma, Pancreatic Ductal; Pancreatic Intraductal Neoplasms; Ulcer; Portal Vein; Peptic Ulcer; Retrospective Studies
PubMed: 37144793
DOI: 10.1177/00031348231175137 -
European Journal of Trauma and... Oct 2017Marginal ulcer (MU) is defined as ulcer on the jejunal side of the gastrojejunostomy (GJ) anastomosis. Most MUs are managed medically but those with complications like...
PURPOSE
Marginal ulcer (MU) is defined as ulcer on the jejunal side of the gastrojejunostomy (GJ) anastomosis. Most MUs are managed medically but those with complications like bleeding or perforation require intervention. It is recommended that GJ anastomosis be revised in patients with MU perforation (MUP). The aim of this case series is to study the clinical presentation and management of MUP.
METHODS
Three hundred and thirty-two patients who underwent emergency surgery for perforated peptic ulcer at a single center were studied over a period of 5 years.
RESULTS
Nine patients (2.7 %) presented with MUP. GJ was previously done for either complicated peptic ulcer (n = 4) or for suspected gastric malignancy (n = 5). Two patients had previously completed H. pylori therapy. None of the patients presented with septic shock. MU was on the jejunal side of GJ in all patients. The median MUP size was 10 mm. Four patients (44.4 %) had omental patch repair, three (33.3 %) had primary closure, and one each had revision of GJ and jejunal serosal patch repair. There were no leaks, intra-abdominal abscess or reoperation and no malignancies.
CONCLUSION
MUP patients do not present with septic shock. Omental patch repair or primary closure is sufficient enough. Revision of Billroth-II-GJ into Roux-en-Y-GJ is not mandatory.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Peptic Ulcer; Peptic Ulcer Perforation; Reoperation; Retrospective Studies; Singapore
PubMed: 27619359
DOI: 10.1007/s00068-016-0723-0 -
Nihon Shokakibyo Gakkai Zasshi = the... 2021Marginal ulcer after pancreatoduodenectomy (PD) is a relatively common complication, but if massive bleeding or ulcer perforation occurs together with the marginal...
BACKGROUND
Marginal ulcer after pancreatoduodenectomy (PD) is a relatively common complication, but if massive bleeding or ulcer perforation occurs together with the marginal ulcer, this condition may be fatal.
OBJECTIVE
To identify the risk factors and management of marginal ulcer after PD.
METHODS
In all, 438 patients who underwent PD from 2003 to 2017 were retrospectively reviewed and analyzed. After surgery, all patients were administered a histamine H2 receptor antagonist (H2RA) or a proton pump inhibitor (PPI), which was continued after discharge. Marginal ulcer was diagnosed by endoscopy or surgery. The risk factors for marginal ulcer were then investigated using univariate and multivariate analyses.
RESULTS
After a median follow-up time of 2.7 years, 29 patients (6.6%) developed marginal ulcer. Seventeen patients developed marginal ulcer within 1 year after PD, and 7 patients developed marginal ulcer more than 3 years after PD. All 8 patients who underwent surgery for the treatment of marginal ulcer developed acute peritonitis. Two patients with acute peritonitis died within 1 month after surgery. A multivariate analysis found that discontinuation of PPI treatment was the only independent risk factor for marginal ulcer development (P<0.001). In contrast, sex, age, primary disease, procedure, operation time, volume of blood loss, pancreatic texture, development of postoperative pancreatic fistula, postoperative complications, poor glycemic control after PD, and discontinuation of H2RA therapy after PD were not significantly different between the patient group that developed marginal ulcer and the patient group that did not. Sixteen patients were not treated with antacids at the time of marginal ulcer development. The reason for discontinuation of antacids was the decision of the family physician in 8 cases and the decision of the patient in 3 cases.
CONCLUSION
Marginal ulcer can still develop a long time after PD, and sometimes, it may be fatal. PPI administration should be continued even after a long time has passed, although this therapy is often discontinued for various reasons. It is therefore important for family physicians and patients to recognize the danger of marginal ulcer after PD.
Topics: Histamine H2 Antagonists; Humans; Pancreaticoduodenectomy; Peptic Ulcer; Proton Pump Inhibitors; Retrospective Studies
PubMed: 33431751
DOI: 10.11405/nisshoshi.118.61 -
Surgery For Obesity and Related... Feb 2021One anastomosis gastric bypass (OAGB) is gaining favor. Anastomotic perforation is a dreaded complication.
BACKGROUND
One anastomosis gastric bypass (OAGB) is gaining favor. Anastomotic perforation is a dreaded complication.
OBJECTIVES
To describe a series of patients presenting with delayed (> 90 days) perforation of a marginal ulcer (MU) following OAGB.
SETTING
Two university hospitals, Israel.
METHODS
A retrospective query identifying patients after OAGB admitted with delayed MU perforation. Demographic characteristics, time between OAGB to presentation, clinical, laboratory and imaging at presentation and management data were collected.
RESULTS
Between 1/2017-1/2020, 7 patients were identified. Mean body mass index (BMI) and time difference between OAGB and perforation were 14 kg/m (range 7-23) and 13 months (range 4-23), respectively. All presented with upper abdominal pain, 4 had concomitant nausea and vomiting. One patient displayed tachycardia, none had fever and 3 exhibited leukocyte abnormalities. C-reactive protein ranged widely (2-311 mg/L). Mean albumin level was 2.9 g/dL (range 1.9-4). Pneumoperitoneum was demonstrated in half of plain abdominal films and all computed tomography (CT) scans. Management was tailored to clinical status. Four patients underwent laparoscopic primary repair with omentopexy. Two patients were initially managed nonoperatively, one eventually requiring conversion to Roux-en-Y gastric bypass (RYGB) while the other recovered without further intervention. One patient underwent exploratory laparotomy and "damage control" management with pouch gastrostomy and double-barrel jejunostomy. Risk factors for MU were present in 4 cases. Mean length of hospital stay was 18 days (range 3-79 days).
CONCLUSIONS
Perforation of MU may occur months to years after OAGB even without risk factors. Laboratory results are unreliable. The CT scan is diagnostic. A tailored approach can achieve good outcomes.
Topics: Gastric Bypass; Humans; Israel; Obesity, Morbid; Peptic Ulcer; Retrospective Studies
PubMed: 33268323
DOI: 10.1016/j.soard.2020.09.022 -
The Surgical Clinics of North America Dec 1976
Review
Topics: Gastrectomy; Gastrins; Humans; Hyperparathyroidism; Pepsinogens; Peptic Ulcer; Vagotomy; Zollinger-Ellison Syndrome
PubMed: 793062
DOI: 10.1016/s0039-6109(16)41096-0 -
Surgical Endoscopy Oct 2012The definition of marginal ulcer after Roux-en-Y gastric bypass (RYGB) is widely debated. This study reviewed findings of upper endoscopy in symptomatic patients at a...
BACKGROUND
The definition of marginal ulcer after Roux-en-Y gastric bypass (RYGB) is widely debated. This study reviewed findings of upper endoscopy in symptomatic patients at a quaternary bariatric referral center. Further investigation included symptom constellation, potential etiologies, and efficacy of treatment for patients found to have marginal ulcer.
METHODS
Patients presenting for upper gastrointestinal endoscopy after Roux-en-Y gastric bypass were included in this study. An institutional review board-approved database was queried for the period 1 June 2010 to 31 August 2011. Subgroup analysis was performed for patients with marginal ulcer. Statistical analysis was performed using PASW version 18 for Windows.
RESULTS
During the study period, 455 upper gastrointestinal endoscopies were performed for 328 consecutive symptomatic patients. Marginal ulcer, found in 112 patients (34 %), was diagnosed for 59 of the patients (53 %) within 12 months after surgery and for 53 of the patients (47 %) more than 12 months after surgery. In patients found to have marginal ulcer, the most common presenting symptoms were pain, dysphagia, nausea, and vomiting. All the patients with marginal ulcer underwent acid suppression and cytoprotective therapy. Using uni- and multivariate analyses for healing, nonhealing, and healing with recurrence, tobacco use was found to be the solitary significant risk factor for recurrence (p = 0.01).
CONCLUSION
Patients with pain or dysphagia after gastric bypass warrant upper endoscopy given the high yield for abnormalities. Although the risk factors for the development of marginal ulcer remain multifactorial, a thorough investigation for potential etiologies including tobacco, alcohol, and nonsteroidal antiinflammatory drug (NSAID) usage should be determined and eliminated. The presence of multiple risk factors may pose a higher challenge in ulcer resolution, leading to increased recurrence. In the current series, prior or current tobacco use remained the sole independent risk factor for ulcer persistence.
Topics: Abdominal Pain; Adolescent; Adult; Aged; Aged, 80 and over; Anastomosis, Surgical; Biopsy; Deglutition Disorders; Female; Gastric Bypass; Humans; Incidence; Male; Middle Aged; Nausea; Obesity, Morbid; Peptic Ulcer; Recurrence; Risk Factors; Stomach; Vomiting; Young Adult
PubMed: 22543994
DOI: 10.1007/s00464-012-2280-x