PROTEIN PUMP INHIBITOR METABOLISM IS ALTERED IN A SIGNIFICANT PORTION OF BARIATRIC CANDIDATES AND MAY BE ASSOCIATED WITH EARLY MARGINAL ULCERATION AFTER GASTRIC BYPASS
Anahita D. Jalilvand*, Omar Zaki, Jane Dewire, Bradley J. Needleman, Sabrena Noria
General Surgery, Ohio State Medical Center, Hilliard, OH
INTRODUCTION: Marginal ulcerations are a significant and morbid complication following Roux-en-Y gastric bypass (RYGB). For this reason, proton pump inhibitor (PPIs) therapy is administered prophylactically to bariatric patients after RYGB to prevent ulcer development. However, numerous studies have documented that the presence of "rapid"? PPI metabolism, may undermine its effectiveness. As such, the goal of this study was to compare preoperative endoscopic findings and marginal ulcer formation in patients with and without altered PPI metabolism.
METHODS: One hundred bariatric patients (50=RYGB, 50=sleeve gastrectomy (SG)) were prospectively enrolled to undergo genetic testing pertinent to drug metabolism for a comprehensive panel of medications using a commercially available pharmacogenetic testing kit for the activity of cytochrome P450 in drug metabolism. Patients were grouped by whether they were fast-metabolizers (fast-met) for PPIs (defined as either rapid or ultra-metabolizers), or normal metabolizers (control). Preoperative endoscopic findings for patients on PPIs at baseline and rates of early (within 90 days) and late ulceration (90-180 days) were compared between groups. A p < 0.05 was considered statistically significant.
RESULTS: Twenty-nine percent (n=29) of this cohort met criteria for fast-met. There was no difference in baseline body-mass index, age, gender, or former smoking status between both groups. Within those treated with a PPI at baseline, fast-met patients demonstrated a trend towards higher incidences of chemical gastritis on preoperative endoscopy (91% vs 63%, p=0.12), while detection of H pylori, Barrett's esophagus, and gastritis, secondary to gastroesophageal reflux disease, were non-significant between groups. Nine patients (18%) who underwent RYGB developed marginal ulcers within 6 months of the index operation, of which 5 (56%) were diagnosed within 90 days and categorized as early ulcers. Development of early ulceration was higher in fast-met patients compared to controls (13% vs 8%, p=0.62), although this did not achieve statistical significance. All late ulcerations occurred within the control group.
CONCLUSION: Significantly altered PPI metabolism was present in nearly 1/3 of bariatric patients. Although not significant, fast-met patients also exhibited a higher incidence of early marginal ulceration following RYGB. Given the importance of PPI prophylaxis in preventing marginal ulceration after RYGB, future, well-powered studies are needed to determine the clinical implications of rapid PPI metabolism in this unique population.
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