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Marginal Ulcerations Occur Later than Previously Described and Have a Long and Variable Time to Resolution
Allison Schulman*, Aoife Devery, Christopher C. Thompson
Division of Gastroenterology, Brigham & Women's Hospital, Boston, MA
Introduction: Ulceration at the gastrojejunal anastomosis (GJA), also known as marginal ulceration, is a common complication of Roux-en-Y gastric bypass (RYGB). While these ulcerations are thought to occur early in the post-operative course, large prospective trials are lacking.
Aims: To determine (1) the time to marginal ulcer diagnosis and (2) ulcer resolution in RYGB patients.
Methods: This was a multi-center retrospective review of a prospectively collected database. Primary outcome was time to ulcer diagnosis (days). Secondary outcome was time to ulcer resolution (days). All patients who underwent RYGB were prospectively enrolled in the Research Patient Data Registry, and all patients found to have marginal ulceration on endoscopy were reviewed for inclusion in this analysis. Maximum medical management including therapy with high dose PPI was initiated in all cases, and repeat endoscopy was performed as per surveillance recommendations until ulcer healing was confirmed. Only patients with follow-up after the index endoscopy were included in time to resolution analysis. Means and medians were compared with Student’s t-test or Wilcoxon based on normality of the data, respectively. Proportional comparisons between groups were performed with Fisher’s Exact test. All statistics are reported as mean ± SEM or median[IQR]. Multivariate regression analysis was also performed.
Results: 340 patients (age 51.7 ± 0.6yr, 253F / 53M) had pre-RYGB BMI of 47.0± 0.5 kg/m2. 225 were performed laparoscopically. Baseline characteristics are shown in Table 1. Median time to development of marginal ulceration was 628.5 [157, 1,690] days after RYGB, and was significantly earlier in patients who had undergone laparoscopic vs. open RYGB procedures (451 vs. 1551 days, p=<0.001). Median time to ulcer healing was 124.0 [76, 267] days. No difference was found in median time to ulcer healing between laparoscopic and open RYGB procedures (116.5 vs. 128.0 days, p =0.71). Multivariable regression analysis demonstrated that having a laparoscopic RYGB (p<0.001) and fistula development (p=0.03) significantly decreased time to marginal ulcer diagnosis when controlling for ulcer size, smoking status, H. pylori infection, non-steroidal anti-inflammatory (NSAID) use, gastric pouch length, and foreign body (suture/staple material). Furthermore, having a laparoscopic procedure (p=0.04) significantly decreased time to ulcer healing when controlling for other variables.
Conclusions: Time to marginal ulcer diagnosis in RYGB patients appears to be considerably later than previously described. Significant differences in time to diagnosis are seen in patients who underwent laparoscopic versus open RYGB procedures, and in those with gastrogastric fistula. Given the long and variable time to resolution, endoscopy to confirm ulcer healing is critical in the management of this complication.
Table 1: Baseline characteristics
| | Laparoscopic RYGB
(n=225)
| Open RYGB
(n=115)
| p-value | | Sex (%F) | 80.0 | 87.4 | 0.60 | | Age (mean ± SEM) | 51.2 ± 0.8 | 52.1 ± 1.1 | 0.60 | | Risk factors for GJA ulcers: | | | | | Smoking (%) | 20.3 | 22.6 | 0.75 | | Diabetes (%) | 20.2 | 15.5 | 0.40 | | Helicobacter Pylori (%) | 14.1 | 9.6 | 0.43 | | NSAID use (%) | 12.6 | 16.5 | 0.45 | | Gastrogastric fistula (%) | 3.0 | 15.6 | <0.001* | | Foreign body material (%) | 42.9 | 34.4 | 0.20 | | Steroids (%) | 6.1 | 6.0 | 1.0 | | Gastric pouch length (mean ± SEM) | 4.6 ± 0.2 | 6.5 ± 0.3 | <0.001* |
C.I. = 95% confidence interval. *denotes p-value <0.05, NS denotes non-significance.  Figure 1: Median time to ulcer development (days) in patients who underwent laparoscopic versus open Roux-en-Y gastric bypass.
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