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Adam Di Palma*, Azusa Maeda, Timothy Jackson, Allan Okrainec
Department of Surgery, University Health Network, Toronto, ON, Canada

Marginal ulcer (MU) formation is a known complication following Roux-en-Y gastric bypass (RYGB) for weight loss. Although most respond to medical treatment, many patients have recurrent or chronic MU demanding significant diagnostic and therapeutic resources, with some requiring surgical revision of their gastro-jejunal (GJ) anastomosis. The goal of this study was to define the incidence of MU and revisional surgery, describe the outcomes following these procedures and quantify the use of clinical resources by patients with MU.

All patients undergoing RYGB between 2011 and 2017 at an academic centre in Toronto, Ontario were included. Patients with a post-operative diagnosis of MU were identified from the institution's bariatric database and had their medical records reviewed. Baseline patient characteristics, timing of diagnosis and management, utilization of endoscopy and imaging studies, and outcomes following revisional surgery were all collected for statistical analysis.

A total of 2,830 RYGB were performed during the study period: 194 with a diagnosis of MU (6.9%), 128 with a single medically-treated episode (4.5%), 39 with recurrent MU responsive to medical therapy (1.4%) and 27 requiring surgical revision (1%). Patients requiring surgical revision developed MU earlier following RYGB than patients with a medically-treated recurrent MU or a single episode of MU (11.1 vs. 12.3 and 19.5 months respectively, p=0.09). Additionally, they required a greater number of upper endoscopies (4.1 vs. 3.6 and 2.2, p<0.001) and CT scans (2.2 vs. 1.3 and 0.8, p<0.001) during follow-up. In all cases, surgical revision consisted of resection and revision of the GJ anastomosis. A gastro-gastric fistula was found and resected in 44% of cases. Recurrent MU following revisional surgery occurred in 56% of patients with only 37% reporting resolution of their symptoms and 11% requiring a second revisional procedure.

MU remains an important problem following RYGB with many presenting recurring episodes and some requiring surgical revision for intractable or recurrent ulceration. Patients requiring surgical revision develop MU significantly earlier than other patients with medically-responsive MU and undergo a greater number of diagnostic endoscopic and imaging studies. Revisional surgery seems to be only moderately successful, as over half of patients develop recurrent MU.

Rate of Marginal Ulceration Following RYGB
All patients with MU1946.9%
Single episode of MU (medically-treated)1284.5%
Recurrent MU (medically-treated)391.4%
Recurrent MU (surgically-treated)271.0%
All recurrent MU682.4%
Total (all RYGB patients)2,830100.0%

MU, marginal ulcer; RYGB, Roux-en-Y gastric bypass.

Time to Marginal Ulceration and Healthcare Utilization
 Single episode MURecurrent MU (medically-treated)Recurrent MU (surgically-treated)All MUp-value
Mean time between RYGB and MU diagnosis (months)19.512.311.116.90.09
Mean number of UGIE2.<0.001
Mean number of abdominal CT scans0.<0.001

MU, marginal ulcer; RYGB, Roux-en-Y gastric bypass; UGIE, upper gastrointestinal endoscopy; CT, computed tomography.

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