HONOLULU — Marginal ulceration is a common complication after Roux-en-Y gastric bypass surgery—and 6–12 months of postoperative prophylactic proton pump inhibitor therapy may protect patients at high risk, Dr. Jason A. Wilson reported at the annual meeting of the American College of Gastroenterology.
Dr. Wilson and coworkers reviewed the charts of 1,001 patients who underwent open or laparoscopic Roux-en-Y bypass at the Medical University of South Carolina, Charleston. In all, 226 patients developed GI symptoms leading to referral for upper GI endoscopy.
Endoscopy revealed that 44% of patients showed normal postsurgical anatomy. However, 36% of the 226 patients had an ulcer at the anastomotic margin, 13% had stomal stenosis, and 4% had staple line dehiscence, Dr. Wilson said.
The use of a proton pump inhibitor after the surgery was associated with a 68% reduction in the relative risk of marginal ulceration. Dr. Wilson speculated that marginal ulcers are caused by increased gastric acid production in the setting of surgically induced mucosal disruption and ischemia, and that proton pump inhibitor therapy is partially protective because it squelches acid production by parietal cells in the gastric pouch.
Smokers had a 41.5-fold greater risk of developing marginal ulceration than did nonsmokers. Patients on NSAIDs had an 11.2-fold increased risk.
Neither alcohol intake nor patient demographics proved to be related to an increased risk of abnormal endoscopic findings.
Patients with a symptomatic marginal ulcer or stomal stenosis presented for endoscopy a mean of 2 months post surgery. Only 4 of 81 patients with a marginal ulcer presented after 12 months. In contrast, patients with staple line dehiscence presented a mean of 22 months after surgery.
There was a trend for nausea and vomiting to predict stomal stenosis at endoscopy. With that exception, a patient's symptoms were not predictive of what would be found at endoscopy.
The incidence of marginal ulceration dropped off drastically by about 6–8 months, presumably because some sort of adaptation occurred. This may have involved the breakdown of ulcerogenic suture material and revascularization at the stomal site, he said.
“At our institution, if you have Roux-en-Y bypass surgery, you have about a 25% chance of being referred for endoscopy and, once scoped, about a 60% chance of our finding an abnormality directly related to the surgery,” Dr. Wilson said.
Technical surgical factors, including choice of suture material, stomal tension, and orientation of the surgically created gastric pouch, are known to contribute to these complications, he said.