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Advances in the prevention and treatment of anastomotic stricture and marginal ulcer after metabolic and bariatric surgery
LI Qin, LIU Yan-jun, WANG Hai-bo, JIANG Qiu-bai, YANG Yun-ning
Chinese Journal of Practical Surgery ›› 2026, Vol. 46 ›› Issue (9) : 1286-1291.
PDF(1301 KB)
PDF(1301 KB)
Advances in the prevention and treatment of anastomotic stricture and marginal ulcer after metabolic and bariatric surgery
Metabolic and bariatric surgery (MBS) is an important treatment for severe obesity and its metabolic comorbidities. With increasing procedural volume and longer follow-up, long-term complications such as anastomotic stricture and marginal ulcer (MU) have drawn growing attention because of their effects on surgical outcomes and patients’ quality of life. Both complications are driven by multiple factors and require a stratified, stepwise, diagnostic and therapeutic pathway; standardized risk assessment, prevention throughout care, and timely intervention are central to improving their clinical management. Anastomotic stricture is associated with local ischemia, anastomotic tension, subclinical leakage, anastomotic technique, and foreign-body reactions. Prevention and treatment should span the perioperative period, including preoperative smoking cessation and nutritional optimization, preservation of anastomotic blood supply and creation of a tension-free anastomosis, and postoperative dietary progression and symptom monitoring. Endoscopy is the mainstay of diagnosis, and treatment should follow a stepwise pathway from endoscopic balloon dilation, adjunctive incision or injection, and stent placement to surgical revision. MU is associated with acid exposure, mucosal ischemia, gastrogastric fistula, pouch size, anastomotic and suture techniques, smoking, nonsteroidal anti-inflammatory drug use, and diabetes. High-risk patients should undergo targeted screening, receive proton pump inhibitor prophylaxis, and maintain long-term lifestyle interventions. Once MU is diagnosed, management should focus on eliminating risk factors, suppressing acid, and protecting the mucosa; recurrent or refractory cases may require endoscopic suturing, stent coverage, foreign-body removal, or surgical reconstruction. Current evidence is derived mainly from single-center retrospective studies. Standardized definitions of complications, a national registry, and prospective multicenter studies are urgently needed to improve the system of stratified prevention, early recognition, stepwise treatment, and multidisciplinary collaboration.
metabolic and bariatric surgery / anastomotic stricture / marginal ulcer / sleeve gastrectomy / gastric bypass / endoscopic treatment
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Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.
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Gastrojejunostomy anastomotic strictures are a complication of Roux-en-Y gastric bypass surgery without an established treatment guideline. A systematic review and meta-analysis were performed to determine the safety and efficacy of endoscopic dilation in their management. PubMed, Web of Science, and Cochrane Central (1994-2017) were searched. Data was analyzed with random effects meta-analysis and mixed effects meta-regression. Twenty-one observational studies (896 patients) were included. The stricture rate for laparoscopic patients was 6% (95% CI, 5-9%). Only 38% (95% CI, 30-47%) required greater than one dilation. Symptom improvement occurred in 97% (95% CI, 94-98%). The complication rate was 4% (95% CI, 3-6%). Endoscopic dilation of GJA strictures is safe, effective, and sustaining. This study can guide endoscopists in the treatment of a common bariatric surgical complication.
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Gastrojejunal (GJ) anastomotic strictures are a challenging complication following Roux-en-Y gastric bypass (RYGB) and may be refractory to conventional balloon dilation. Lumen-apposing metal stents (LAMS) provide anchored, wide-caliber support that may treat strictures, yet long-term outcomes remain variable, and stent migration is a concern. This study evaluates the clinical effectiveness and safety of LAMS with or without concurrent endoscopic stricturoplasty in patients with GJ strictures.
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Stricture of the gastrojejunostomy after Roux-en-Y gastric bypass (RYGB) is common in the early postoperative period, with a reported incidence of 3-27%. Late recalcitrant strictures are much less common. Treatment has varied from endoscopic therapy to operative revision of the gastrojejunostomy with or without additional anatomic revisions. The origin of the late strictures varies, with the most common causes being excessive acid, aspirin, or nonsteroidal anti-inflammatory drug use, postoperative anastomotic leak, or, as some have maintained, smoking. We sought to identify the predictors of gastrojejunostomy strictures that require operative management after RYGB and to evaluate the clinical outcomes of patients requiring operative revision of the gastrojejunostomy stricture after failed nonoperative therapy at an academic institution.A retrospective review was performed of all patients undergoing operative intervention for gastrojejunostomy stricture from 1990 to 2009 after having undergone RYGB for medically complicated obesity.A total of 24 patients required revision of their gastrojejunostomy stricture after multiple attempts at nonoperative therapy. The mean interval from RYGB to reoperation was 4.3 years (range.5-25). The interval to operative revision for anastomotic stricture was substantially less in patients with active anastomotic ulcers (n = 6), those who had had a gastrojejunostomy leak after RYGB (n = 5), and those with gastrogastric fistulas (n = 7; 20, 23, and 44 months, respectively). Of the 24 patients, 23 experienced relief of their symptoms. The postoperative morbidity rate was 21%, and the mortality rate was 0%.Operative revision of strictured gastrojejunostomy is a safe and effective procedure for those patients in whom endoscopic therapy has failed. Most refractory anastomotic strictures have been secondary to excessive acid (too large a proximal pouch), chronic ulceration, or postoperative anastomotic leak.Copyright © 2011 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
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Marginal ulcers (MU) are a significant postoperative complication following anastomotic metabolic and bariatric surgeries including Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), and biliopancreatic diversion with duodenal switch (BPD/DS). This review summarizes current knowledge on MU risk factors, screening, and prophylactic strategies.The goal of this review is to examine technical and patient-related risk factors for MU, assess screening strategies, and recommend prophylactic approaches to reduce MU incidence after anastomotic metabolic and bariatric surgery (MBS).A comprehensive review was conducted by members of the American Society for Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee, based on available literature from 2000 to the present.A systematic search was performed using Ovid MEDLINE and PubMed databases. Relevant studies were screened for inclusion. Technical and patient-related factors were evaluated, and recommendations for MU prevention were formulated.Several risk factors for MU were identified, including large gastric pouch size, circular stapled anastomoses, use of nonabsorbable sutures, smoking, nonsteroidal anti-inflammatory drugs use, and immunosuppression. While prophylactic proton pump inhibitor (PPI) therapy is widely recommended, its optimal duration remains debated. The role of Helicobacter pylori in MU development is not clearly defined.Prophylactic PPI therapy for at least 3 months postsurgery significantly reduces the risk of MU. Risk stratification and individualized treatment plans are essential to minimize postoperative complications. Further research is needed to clarify the role of H. pylori and optimize prophylactic strategies.Copyright © 2025 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
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Marginal ulcer (MU) is a common complication of Roux-en-Y Gastric Bypass (RYGB). The primary goal of this meta-analysis was to identify potential risk factors for MU post-RYGB.A comprehensive literature search was conducted on four databases (PubMed, Embase, Web of Science, and the Cochrane Library) to identify articles published from inception to 23 May 2023 that reported risk factors linked to ulcer occurrence post-RYGB. Hazard Ratio (HR) and Odds Ratio (OR) with respective 95% CI were calculated to estimate the impact of selected risk factors on MU. The risk factors were evaluated through multivariate analyses. The estimated risk factors were subjected to a random-effects model. Subgroup analysis based on study baseline characteristics and leave-one-out sensitivity analysis were also performed to investigate the potential sources of heterogeneity and assess the robustness of the findings.Herein, 14 observational studies involving 77 250 patients were included. Diabetes, smoking, and steroid use were identified to be risk factors of MU, with pooled ORs of (1.812; 95% CI: 1.226-2.676; P=0.003), (3.491; 95% CI: 2.204-5.531; P<0.001), and (2.804; 95% CI: 1.383-5.685; P=0.004), respectively. Other risk factors, such as alcohol consumption, male sex, and PPI use, were deemed not significant due to differences in data acquisition and effect estimates.Diabetes, smoking, and steroid use were identified as independent risk factors of MU. Enhancing awareness of these identified risk factors will lead to more effective preoperative prevention and targeted postoperative interventions for patients undergoing RYGB.Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
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Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU.All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively.In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m. The median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58-26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively.MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.
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Marginal ulcer (MU) is an occasional complication after gastric bypass. We studied the incidence of this complication by a prospective routine endoscopic evaluation.441 morbidly obese patients were studied prospectively. There were 358 women and 97 men, with mean age 41 years and mean BMI 43 kg/m(2). An endoscopic evaluation was performed in all 1 month after surgery, which was repeated in 315 patients (71%) 17 months after surgery, independent of the presence or absence of symptoms. Patients were submitted either to laparotomic resectional gastric bypass (360 patients), employing a circularstapler-25 or to laparoscopic gastric bypass (81 patients), in whom a hand-sewn anastomosis was performed.One month after surgery, 15 patients (4.1%) of the 360 laparotomic gastric bypass and 10 (12.3%) of the 81 laparoscopic gastric bypass presented an "early" marginal ulcer (p < 0.02). Seven patients among the 25 with MU were asymptomatic (28%). Endoscopy was repeated 17 months after surgery. Among 290 patients with no early MU, one patient (0.3%) presented a "late" MU 13 months after surgery. From the 25 patients with "early" MU, one patient (4%) presented a "late" MU. All these patients were treated with PPIs.By performing prospective routine endoscopic study 1 month and 17 months after gastric bypass, two different behaviors were seen regarding the appearance MU: (a) "early" MU, 1 month after surgery in mean 6% and (b) "late" MU, in a very small proportion of patients (0.6%). Among patients with "early" MU, those who had undergone resectional gastric bypass showed significantly less ulcers compared to those patients in whom the excluded distal gastric segment had been left in situ. The operative method may play a significant role in the pathogenesis of MU after gastric bypass.
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In the late post-operative period, the necessity of performing an upper gastrointestinal endoscopy (GIE) to check for complications is controversial. Some authors suggest it should be routine for all patients, others selectively, but not all patients with endoscopic abnormalities are symptomatic and some abnormalities are potentially severe. The study was conducted to evaluate the endoscopic findings from asymptomatic obese patients after Roux-en-Y gastric bypass (RYGB) and correlate them with the demographic data and the presence of Helicobacter pylori (Hp).A total of 715 asymptomatic patients were prospectively submitted to an upper GIE at the end of their first post-operative year. These examinations were evaluated for the presence of abnormalities, their prevalence and their potential severity.Abnormalities were found in 189 patients (26.5 %). Eighty-four (11.7 %) presented esophageal abnormalities, with 72 (10.1 %) characterized as esophagitis and 12 (1.7 %) as hiatal hernia. Forty-five patients (6.3 %) presented abnormalities of the stomach and the anastomosis, with 26 (3.6 %) characterized as anastomotic ulcers, nine (1.3 %) as stenosis of the gastrojejunal anastomosis, ten (1.4 %) as band erosion and 72 (10.1 %) as jejunitis. There was a statistically significant correlation between super obesity and band erosion.An upper GIE at the end of the first year of RYGB plays an important role, even for asymptomatic patients. One fourth of these asymptomatic patients had their treatment modified after the upper GIE was performed.
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Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal ulcers. We performed a systematic review to understand the presentation, management, and outcomes of PMUs. PubMed, Google Scholar, and Embase databases were searched to identify all studies on PMUs after gastric bypass procedures. A total of 610 patients were identified from 26 articles. The mean age was 39.8±2.59 years, and females represented most of the cohort (67%). The mean body mass index was 43.2±5.67 kg/m. Most of the patients had undergone a Roux-en-Y gastric bypass (98%). The time gap between the primary bariatric surgery and the diagnosis of PMU was 27.5±8.56 months. The most common presenting symptom was abdominal pain (99.5%) and a computed tomography scan was the diagnostic modality used in 72% of the patients. Only 15% of patients were on prophylactic proton pump inhibitors or H2 blockers at the time of perforation, and 41% of patients were smoking at the time. Twenty-three percent of patients were on nonsteroidal anti-inflammatory drugs. Laparoscopic omental patch repair of the perforation (59%) was the most used technique; 18% of patients underwent open surgery, and 20% were managed non-surgically. Thirty-day mortality was 0.97%; it was 1.21% (n=5) and 0% (n=0) in those who were managed surgically and nonsurgically, respectively. Ulcers recurred in 5% of patients. In conclusion, PMU is a surgical emergency after gastric bypass that can result in significant morbidity and even mortality. This is the first systematic review in scientific literature characterizing this condition.Copyright © 2022 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
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Marginal ulcer (MU) is an uncommon but significant complication following one-anastomosis gastric bypass (OAGB). Our study aims to understand the incidence rates, risk factors, and management of MU following OAGB.MEDLINE, Scopus, and Cochrane Library databases were examined to identify all studies on OAGB where authors had reported on MU. Data were collected on basic demographics, incidence rates, risk factors, and management of this condition.Thirty-two studies involving 8868 patients were analysed. The mean age and body mass index (BMI) of patients in these studies were 40.9 ± 4.5 years and 47.6 ± 5.6 kg/m, respectively. Among the patient cohort, approximately 72% were female, and 20.6% had preoperative gastroesophageal reflux disease (GERD). The authors described prescribing proton-pump inhibitors (PPI) prophylaxis to 14.1% of patients after surgery. Two hundred twenty-eight patients were reported to have MU. The incidence of MU was 2.59% (95% CI 1.89-3.52), of which 53 patients presented within 12 months, 24 patients presented after 31 months, and five patients after 6 years. One hundred forty-six patients did not have presentation time documented. Sixty-five patients were described to have MU diagnosed on endoscopy, of which 54 were symptomatic and 11 were asymptomatic. The authors were, however, not specific on the choice of investigation for the remaining 163 patients. Of patients, 89.7% were treated conservatively with PPIs, whilst 10.3% had surgery to treat MU.Marginal ulcer is an uncommon complication following OAGB. The majority of patients are treated conservatively with PPIs. Larger, well-designed studies reporting on risk factors, investigation, and management of MU following OAGB are warranted.© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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Marginal ulcer (MU) is well-known complication in bariatric surgery. Several studies are available in Roux-en-Y gastric bypass (RYGBP), while data on the incidence in duodenal switch (DS) is limited. We aimed to compare the incidence of MU between DS and RYGBP in a well-defined cohort and to identify associative factors.A cohort of 732 patients with BMI ≥ 48 who had undergone primary DS or RYGBP during 2008-2018 received a questionnaire concerning ulcers, PPI therapy, and smoking habits; hereafter, patient charts were reviewed. Incidence rates (IRs) for MU were calculated in our survey and on previous registered data in the national quality register for bariatric surgery (SOReg). A multivariate regression analysis was performed to identify predictive risk factors for MU.After a mean follow-up of 6.1 years, 472 (64%) patients responded (47 ± 11 years old, 65% women and 42% DS). Of 41 MUs identified, 23 were endoscopically verified. Gastrointestinal bleeding, abdominal pain, and dysphagia were the most common symptoms. IR for MU was 1.4% (DS 1.3% and RYGBP 1.5%) per patient-year, compared with 0.9% according to SOReg-data. Persisting PPI treatment was seen in about three quarter of former MU patients (OR 11.2 [3.6-34.7], p < 0.001), but no other associative factors were found.The overall risk for MU was low, about 1% per patient-year, without difference between DS and RYGBP. Ongoing PPI treatment was frequent in many former MU patients. This study on MU after DS provides reassuring results for future bariatric surgery candidates.
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According to several short-term studies, single-anastomosis sleeve ileal (SASI) bypass offers similar weight loss to Roux-en-Y Gastric Bypass (RYGB) with fewer complication and better comorbidity reduction/resolution. Long-term data on this operation is lacking in the literature. The purpose of this study was to analyze the outcomes of SASI bypass up to 4 years.This study is a retrospective cohort analysis of 366 patients with morbid obesity who underwent primary SASI bypass from January 2018 to February 2022.The mean age and preoperative body mass index (BMI) were 41 years (range 22-71 years) and 43.9 ± 6.5 kg/m, respectively. Follow-up was available for 229 patients at 1-year (89%), 112 patients at 2-year (75%), 61 patients at 3-year (75%), and 35 patients at 4-year (71%). The intraoperative, short-term, and long-term complication rates were 0%, 2.5%, 4.6%, respectively. After 4 years, mean percentage excess weight loss (%EWL) was 93.3% and total weight loss (%TWL) was 41.2%. Remission of comorbidities was 93% for type 2 diabetes mellitus, 73% for hypertension, 83% for hyperlipidemia, 79% for sleep apnea, and 25% for gastroesophageal reflux disease (GERD). Biliary gastritis and ulcers are seldom. Eight patients developed de novo GERD symptoms requiring proton pump inhibitor treatment. None of the patients in our study had hypoalbuminemia or malabsorption that did not respond to increased protein intake and vitamin or mineral supplementation.SASI bypass appears to be safe, and one of the most effective bariatric procedures regarding weight loss and obesity related comorbidities. The double-outlet created in this procedure seemingly minimizes nutritional complications.© 2023. The Author(s).
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Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.
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Marginal ulcers are one of the most common complications after gastric bypass. Reported incidence varies widely (0.6-16 %) and pathogenesis is unclear. The aim of the present study was to describe characteristics, risk factors, management, and outcomes of endoscopically documented ulcers.Data from all patients diagnosed with marginal ulcers at endoscopy between 2003 and 2010 were retrospectively reviewed.A total of 103 patients with marginal ulcers presented with pain (63 %) and/or bleeding (24 %), a median of 22 months after surgery. Ulcers were located on the anastomosis (50 %) or the jejunum (40 %); sutures were visible in 35 %, and gastrogastric fistulae in 8 %. The mean pouch length was 5.6 cm. Diabetes (odds ratio [OR] 2.5; P = 0.03), smoking (OR 2.5; P = 0.02), and gastric pouch length (OR 1.2; P = 0.02) were significantly associated with marginal ulcer formation on univariate analysis; diabetes was significantly associated on multivariate analysis (OR 5.6; P = 0.003). The risk of developing a marginal ulcer decreased with time (OR 0.8; P < 0.01) and was not associated with the use of nonsteroidal anti-inflammatory drugs. At first endoscopic follow-up, 67 % of ulcers had healed. Recurrence occurred in four patients and nine patients required surgical revision.The vast majority of marginal ulcers had a favorable outcome after medical treatment. However, 9 % of patients eventually required surgical revision. Therefore, endoscopic follow-up is essential. Diabetes, smoking, and long gastric pouches were significant risk factors for marginal ulcer formation, suggesting increased acid exposure and mucosal ischemia are both involved in marginal ulcer pathogenesis. Management of these factors may prove effective in managing marginal ulcers, and tailoring postoperative proton pump inhibitor therapy to patients with multiple risk factors could be effective.© Georg Thieme Verlag KG Stuttgart · New York.
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Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures worldwide, but the importance of gastric pouch size is still under debate. We have studied how pouch size affects risk of marginal ulcer and excess body mass index loss (EBMIL%) at 6 weeks and 1 year postoperatively.Scandinavian Obesity Surgery Registry included 14,168 LRYGB patients with linear stapled gastrojejunostomies, having complete pre- and postoperative data concerning length of stapler needed to complete the gastric pouch, incidence of marginal ulcers and weight loss. LRYGB technique in Sweden is highly standardized, and total length of stapler was used as a proxy for pouch size.Mean length of stapler used for the pouch was 145 mm. At 1 year, symptomatic marginal ulcers were noted in 0.9 % of the patients. The relative risk of marginal ulcer increased by 14 % (95 % confidence interval 9-20 %), for each centimeter of stapler used for the pouch. Body mass index (BMI) was reduced from 42.4 ± 5.1 to 36.1 kg/m(2) at 6 weeks and 28.9 kg/m(2) at 1 year. The total length of stapler predicted EBMIL% at 6 weeks but not at 1 year. Female gender, low preoperative BMI, young age and absence of diabetes predicted better EBMIL% at 1 year.A smaller pouch reduces the risk of marginal ulcers, but does not predict better weight loss at 1 year. Additional stapling should be avoided as each extra centimeter increases the relative risk of marginal ulcers by 14 %.
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It has been suggested that shortening the length of the biliopancreatic limb (BPL) to 150 cm in one anastomosis gastric bypass (OAGB) would reduce nutritional complication rates without impairing weight loss outcomes. The aim of this study is to compare patients who underwent OAGB with a 200-cm BPL (OAGB-200) to patients with OAGB with a 150-cm BPL (OAGB-150) in terms of weight loss and late morbidity.This is a monocentric retrospective matched cohort study including patients with a body mass index between 35 and 50 kg/m who underwent an OAGB-150 or an OAGB-200. Patients were matched 1:1 based on age, sex, and body mass index, prior to bariatric surgery.In total, 784 patients who underwent OAGB were included (OAGB-150 n = 392 and OAGB-200 (n = 392). There was no significant difference in terms of early morbidity. Regarding late morbidity in patients with an OAGB-150, significantly lower rates for marginal ulcer (OR = 0.4, CI 95% [0.2; 0.8], p = 0.006), incisional hernia (OR = 0.5, CI 95% [0.3; 1], p = 0.041), and bowel obstruction (OR = 0.3, CI 95% [0.1; 0.9], p = 0.039) were reported. Likewise, regarding late nutritional deficiencies, post-OAGB-150, a significantly lower number of patients with hypoalbuminemia (OR = 0.3, CI 95% [0.2; 0.7], p = 0.006), low vitamin B9 (OR = 0.5, CI 95% [0.2; 1], p = 0.044), and low ferritin (OR = 0.5, CI 95% [0.3; 0.8], p = 0.005) were observed. There was no significant difference in the percentage of excess BMI loss at 1, 2, 3, 4, and 5 years.Compared to OAGB-200 in patients with BMI ≤ 50 kg/m, OAGB-150 results in fewer nutritional deficiency rates long term, without impairing weight loss.© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures.PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies.Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications.This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.© 2020. Springer Science+Business Media, LLC, part of Springer Nature.
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| [38] |
A precipitating factor for marginal ulcer formation after Roux-en-Y gastric bypass may be the prolonged irritation by foreign material, such as nonabsorbable suture at the gastrojejunostomy. This study examines the incidence of marginal ulcers before and after a change was made from using nonabsorbable suture to using absorbable suture for the inner layer of the anastomosis.A total of 3285 laparoscopic Roux-en-Y gastric bypass operations were performed during a 5-year period. The gastrojejunostomy technique was modified in August 2002. Those patients who developed a marginal ulcer postoperatively were identified, and their charts were retrospectively analyzed for the operative technique, patient age, history of previous gastric surgery, presence of preoperative diabetes, coronary artery disease, or peptic ulcer disease, and use of nonsteroidal anti-inflammatory medications or tobacco.The incidence of marginal ulceration after Roux-en-Y gastric bypass decreased significantly from 2.6% (28/1095) with the use of nonabsorbable suture to 1.3% (29/2190) after the change to absorbable suture for the inner layer of the gastrojejunal anastomosis (P <.001). The incidence of visible suture adjacent to the ulcer on endoscopy was also significantly reduced (64.3% vs 3.4%; P <.001). When the results were corrected for length of follow-up, the difference in the incidence of ulcers occurring within 1 year of surgery remained significant between the two groups (P =.002). There were no other significant differences in the factors analyzed.The use of nonabsorbable sutures for the inner layer of the gastrojejunal anastomosis is associated with an increased incidence of marginal ulcers, and the adoption of absorbable suture material has reduced this incidence.
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| [39] |
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| [40] |
Marginal ulcer (MU) is a common complication following Roux-en-Y gastric bypass (RYGB) with an incidence rate of up to 25%. Several studies have evaluated different risk factors associated with MU with inconsistent findings. In this meta-analysis, we aimed to identify the predictors of MU after RYGB.A comprehensive literature search of PubMed, Embase, and Web of Science databases was conducted through April 2022. All studies that used a multivariate model to assess risk factors for MU after RYGB were included. Pooled odds ratios (OR) with 95% confidence intervals (CI) for risk factors reported in ≥ 3 studies were obtained within a random-effects model.Fourteen studies with 344,829 patients who underwent RYGB were included. Eleven different risk factors were analyzed. Meta-analysis demonstrated that Helicobacter pylori (HP) infection (OR 4.97 [2.24-10.99]), smoking (OR 2.50 [1.76-3.54]), and diabetes mellitus (OR 1.80 [1.15-2.80]), were significant predictors of MU. Increased age, body mass index, female gender, obstructive sleep apnea, hypertension, and alcohol use were not predictors of MU. There was a trend of an increased risk of MU associated with nonsteroidal anti-inflammatory drugs (OR 2.43 [0.72-8.21]) and a lower risk of MU with proton pump inhibitors use (OR 0.44 [0.11-2.11]).Smoking cessation, optimizing glycemic control, and eradication of HP infection reduce the risk of MU following RYGB. Recognition of predictors of MU after RYGB will allow physicians to identify high-risk patients, improve surgical outcomes, and reduce the risk of MU.© 2023. The Society for Surgery of the Alimentary Tract.
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| [41] |
One of the roles of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) is to provide guidance on the management of patients seeking surgery for adiposity-based chronic diseases. The role of endoscopy around the time of endoscopy is an area of clinical controversy. In 2018, IFSO commissioned a task force to determine the role of endoscopy before and after surgery for the management of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO Endoscopy in Bariatric/Metabolic Surgery Taskforce. It has been approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed regularly.
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| [42] |
Marginal ulcers (MUs) encompass a group of mucosal disruptions and subsequent inflammatory changes and their sequala found after Roux-en-Y gastric bypass (RYGB) oneanastomosis gastric bypass (OAGB), and, less commonly, after biliopancreatic diversion with duodenal switch (BPD/DS) or single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). Prevalence of MU after RYGB ranges from.6%-16%. This review summarizes the current knowledge about the treatment options available for MU after MBS for providers who treat them.Copyright © 2025 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
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| [43] |
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| [44] |
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利益冲突 所有作者均声明不存在利益冲突
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