OPEN-CAPSULE PROTON PUMP INHIBITOR IS ASSOCIATED WITH FASTER HEALING TIME FOR MARGINAL ULCERATION AFTER ROUX-EN-Y GASTRIC BYPASS
Heesoo Yoo*2, Stephen Firkins1, Alvin Kwon2, Kristelle J. Imperio-Lagabon1, Ramanpreet K. Bajwa1, Bailey Flora1, C. Roberto Simons-Linares1
1Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH
Background: Marginal ulceration (MU) is a significant cause of morbidity after Roux-en-Y gastric bypass (RYGB) surgery. Proton pump inhibitor (PPI) therapy is the mainstay of treatment, though the method of administration may vary. There is limited retrospective evidence that the use of "open-capsule" PPI (OC-PPI) improves the healing of MU after RYGB compared to "intact-capsule" PPI (IC-PPI). Yet, the data remains disputable with several confounding factors and effect modifiers that can cloud the result, necessitating further validation. This retrospective cohort study aims to compare the healing times of MU after RYGB when treated with OC-PPI versus IC-PPI.
Materials and Methods: We retrospectively analyzed patients with a history of RYGB who were diagnosed with gastrojejunal MU on endoscopy at a large, tertiary care center from January 1st, 2012 to August 29th, 2022. We identified all patients with documented healing times as treated with either OC-PPI or IC-PPI, followed by 1:4 matching for age and gender. Patients without documented healing, those requiring revision surgery or mechanical closure for treatment-resistant ulcers, and those with unclear PPI administration methods were excluded. The primary outcome was time to ulcer healing. The log-rank test was used to test the null hypothesis (no difference between the MU healing times in the two groups) followed by Kaplan Meier survival curve analysis.
Results: A total of 519 RYGB patients with confirmed MU were included for review. After stringent review, 33 patients were included in the OC-PPI group and 42 in the IC-PPI group for final analysis. There were more females in the IC-PPI group, but no difference in race, age, BMI, concurrent sucralfate usage, or other known risk factors for marginal ulcer formation, aside from the use of non-steroidal anti-inflammatories (NSAIDs), which was more common in the OC-PPI group. There was a significant decrease in mean [standard error] MU healing time by 147 days in the OC-PPI group compared to the IC-PPI group (164.82 [22.70] vs. 311.67 [50.61], respectively [p=0.02]). Kaplan Meier survival curve visualized a distinct divergence of healing time of MU at approximately 100 days (p=0.0135).
Conclusion: Our study showed a significantly shorter MU healing time using OC-PPI compared to IC-PPI in RYGB patients by 147 days. Further, the benefit of OC-PPI over IC-PPI persisted despite higher NSAID use in the OC-PPI group. These results are consistent with prior limited data and further support a growing paradigm shift to the use of OC-PPI as the standard of care in treating MU in gastric bypass patients. By reducing healing time and the need for repeated endoscopic monitoring of MUs, we not only improve bariatric outcomes for patients but also decrease the social and healthcare burden of post-surgical complications.
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