PROPHYLACTIC PROTON PUMP INHIBITORS IN PREVENTION OF MARGINAL ULCERS AFTER GASTRIC BYPASS SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS
Rami Musallam*1, Osama Abu-Shawer2, Mohammad Aldiabat4, Khaled Alsabbagh Alchirazi2, Babu P. Mohan5, Emad Mansoor1, Gregory S. Cooper1, Roberto Simons-Linares2, Mohannad Abousaleh3, Ahmed Shamia2
1Internal medicine, Case Western Reserve University/University Hospitals Cleveland Medical Center, Fairview Park, OH; 2Cleveland Clinic, Cleveland, OH; 3Trinity Health Ann Arbor - Huron Gastro, Ann Arbor, MI; 4NYU Langone Hospital - Long Island, Mineola, NY; 5University of Utah Health, Salt Lake City, UT
Introduction:
Marginal ulcer (MU) is a common complication following bariatric surgery. It mostly presents with abdominal pain and if left untreated, it can be complicated with perforation, bleeding or fistula. Proton pump inhibitors (PPI) are the mainstay of treatment, including primary prophylaxis. In this meta-analysis, we aimed to determine the usefulness of PPI prophylaxis for MU prevention and optimal duration of primary prophylaxis after gastric bypass surgery.
Methods:
We performed a comprehensive literature search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception through November 2022. The primary outcome was the overall incidence of MU following PPI prophylaxis. The secondary outcomes were rate of bleeding, perforation, fistula, and rate of medical, surgical management. Standard meta-analysis methods were employed using a random-effect model using Comprehensive Meta-Analysis Software (CMA). Heterogeneity was assessed using the I2 index.
Results:
17 studies (3 prospective, 14 retrospective) involving 10,999 patients were included. Mean age was 43.4 (10.7) years, and 81 % were female. The type of surgery performed included open (0.9%) and laparoscopic (99%) Roux-en-Y gastric bypass. The type, dose, and duration of prophylactic PPI were variable ranging from 1 to 6 months, postoperatively. Pooled incidence of MU after PPI prophylaxis was 5.3% [(95% confidence interval (CI):3.6-7.8, I2=94%)]. The odds ratio of MU in PPI vs no PPI was 0.42 [0.27-0.66, I2=6%, p<0.001] (5 studies, Figure.1). Subgroup analysis, based on duration of PPI prophylaxis, demonstrated incidence of MU to be 7.4% [3.6-14, I2=95%] in <3 months, 3.8% [3.8-6.6, I2=93%] at 3 months, and 5.1% [ 2-12, I2=83%] at 6 months. The pooled rate of bleeding was 16.2% [5.8-37.9, I2=63%], perforation 9.2% [4.3-18.8, I2=42%], and fistula formation 6.6% [3.9-9.1, I2=0%]. The pooled rate of medical management was 84% [71-92, I2=77%], and surgical was 16.2% [8.7-28.3. I2=74%] (Table.1). No evidence of publication bias was found (Egger's test: P=0.11).
Conclusion:
Based on our meta-analysis, PPI prophylaxis reduced the overall incidence of MU from about 10% to 5.3%. The incidence of MU was higher (7.4%) in the less than 3 months of PPI therapy group. Approximately similar rates of MU were observed in the 3 months and 6 months PPI therapy groups with incidence rates of 3.8 and 5.1%, respectively. Further research is warranted to define the optimal duration of PPI therapy after gastric bypass surgery.
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