Perforated marginal ulcer after gastric bypass for obesity: a systematic review

Martinino, Alessandro; Bhandari, Mayank; Abouelazayem, Mohamed; Abdellatif, Ayman; Koshy, Renol; Mahawar, Kamal

doi:10.1016/j.soard.2022.05.024

Cited by 13 publications

(9 citation statements)

References 39 publications

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“…However, notably these studies reported a 0% 30-day mortality, likely representing a more stable presentation. 1,4 The one remaining patient in the Martino et al study was identified in the paper by Aviran et al, 8 which was included in this systematic review. Coblijn et al noted a patient in 2015 who developed a PMU adjacent to a nasojejunal tube 3 weeks after conversion of adjustable gastric banding to RYGB.…”

Section: Resultsmentioning

confidence: 99%

“…2,3 Management of PMUs is typically prompt surgical intervention, with the goal of addressing the defect and any associated complications, using techniques ranging from omental patching to full revision of the GJ anastomosis. 4,5 While some studies have shown that non-surgical approaches, such as endoscopic suturing, may be effective in managing small bleeding marginal ulcers without the need for surgery, there is limited data on managing PMUs non-operatively. 5,6 In the setting of advanced imaging modalities and thin-slice computed tomography (CT) scanners, there is a subset of patients with "microperforations" that can potentially be successfully managed with non-operative therapy.…”

Section: Introductionmentioning

confidence: 99%

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Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series

Pope,

English,

Walden

et al. 2023

The American Surgeon™

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Background Perforated marginal ulcers (PMUs) are a rare but known complication of bariatric surgery. Management typically involves prompt surgical intervention, but limited data exists on non-operative approaches. This study reviews published data on non-operative management of PMUs and presents a case series of patients who were managed non-operatively. Our hypothesis is that certain patients with signs of perforation can be successfully managed non-operatively with close observation. Methods We completed a systematic review searching PubMed, Embase, Web of Science, Cochrane, and clinicaltrials.gov. Ultimately 3 studies described the presentation and non-operative management of 5 patients. Additionally, we prospectively collected data from our institution on all patients who presented between Dec. 2022 and Dec. 2023 with PMUs confirmed on imaging and managed non-operatively. Results In our literature review, three patients had Roux-en-Y gastric bypass (RYGB), while two had one anastomosis gastric bypass. One patient required surgery two days after admission. Another underwent elective conversion surgery weeks later for a non-healing ulcer. Two received endoscopic interventions. One patient recovered with nil-per-os (NPO) status, and intravenous proton pump inhibitor (PPI) treatment. The patients in our case series presented with normal vital signs, an average of 30 months after RYGB, and with CT scan signs of perforation. None of these patients required surgical or endoscopic intervention. Conclusion In conclusion, while perforated marginal ulcers have traditionally been considered a surgical emergency, some patients can be successfully treated with non-operative management. More research is needed to identify the clinical presentation features, comorbidities, and imaging findings of this group.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series

Pope,

English,

Walden

et al. 2023

The American Surgeon™

View full text Add to dashboard Cite

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“…More complicated procedures including resection/revision of the anastomosis are rarely required and should be avoided in the acute setting. 65,66 A closed-suction drain should be left adjacent to the repair, and we recommend early initiation of oral liquid intake (within 24 to 48 hours) along with acid-suppression therapy and smoking cessation if needed. Prolonged nasogastric decompression and withholding or oral intake is not required for the majority of patients who have early diagnosis of the perforation and timely operative repair.…”

Section: Late Complications (>30 Postoperative Days): Internal Hernia...mentioning

confidence: 99%

“…Intraoperative endoscopy or insufflation of air via a nasogastric tube can be useful in identifying the location of perforation (if not readily apparent) and for testing the completeness of the surgical repair. More complicated procedures including resection/revision of the anastomosis are rarely required and should be avoided in the acute setting 65,66 . A closed-suction drain should be left adjacent to the repair, and we recommend early initiation of oral liquid intake (within 24 to 48 hours) along with acid-suppression therapy and smoking cessation if needed.…”

Section: Gastric Bypass Complicationsmentioning

confidence: 99%

Common postbariatric surgery emergencies for the acute care surgeon: What you need to know

Cheng,

Samakar,

Dobrowolsky

et al. 2023

J Trauma Acute Care Surg

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The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.

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“…Symptoms of MU can vary, with some patients being asymptomatic while others present with nausea/vomiting, abdominal pain, or gastrointestinal (GI) bleeding, potentially explaining the variability in the reported incidence rates [ 8 , 18 ]. In severe cases, MU may perforate and require urgent treatment [ 8 , 19 ]. The timing and severity of presentation often dictate the appropriate course of treatment [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management

Salame,

Jawhar,

Belluzzi

et al. 2023

JCM

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Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.

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Perforated marginal ulcer after gastric bypass for obesity: a systematic review

Cited by 13 publications

References 39 publications

Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series

Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series

Common postbariatric surgery emergencies for the acute care surgeon: What you need to know

Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management

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