Perforated Marginal ulcer after endosurgery for weight regain – history of two cases
EAES Academy. Happ S. 07/05/22; 362958; P001
Sebastian Happ
Contributions
Contributions
Abstract
Introduction
Weight regain seems to be a frequent problem after Roux-en-Y gastric bypass (RYGB). When lifestyle interventions fail, further interventions get necessary. One of the key points in weight regain is the size of the gastrojejunal anastomosis. Re-sizing of a large anastomosis leads to a reduction of the pouch outlet. By this approach, the function of the bypass shall be restored. Beneath revision surgery, the transoral endoscopic outlet reduction is a powerful tool which has shown a high efficiency and safety in different studies.
Methods, Cases and Literature
Two patients with perforated marginal ulcers after endosurgery for weight regain had to be operated in a tertiary center in Switzerland last year. Both had secondary endoscopic reduction 8 respectively 12 years after a RYGP. The perforations happened 6 months respectively 2 years after the intervention. Other risk factors where previous ulcer in one case and short-term NSAID medication in the other. Both were female, 44 and 66 years old. They showed a generalized peritonitis and were treated in an emergency setting. After laparoscopic exploration and lavage an open repair with single stitch suturing, absorbable sutures, PDS 4.0 was performed. In one case, a suture from the Apollo System with its anchor was found in the perforation. Short-term antibiotic therapy and PPI where initialized. Pathology in both cases revealed transmural necrosis, no Helicobacter. Both recovered well, had a follow up endoscopy with a showed no further ulcer and proper healing of the mucosa.
So far, we found no description of a higher incidence of ulcer or even perforations after these endoscopic procedures. After RYGB an incidence of 3-7% of marginal ulcer is reported. The major factors for the development are a triad of inflammation trough foreign body reaction, ischemia by damaged microcirculation and hyperacidity. Usually, the ulcers appear early after surgery with a mean at 12 months.
Conclusion:
In our cases there where many years between the RYGP and the ulcer. In theory, suturing at the gastrojejunostomy could induce an episode of inflammation by additional foreign material. A change in microcirculation by the inflammation or tension on the tissue is also possible. Based on these physiological considerations and on the history of these cases an elevated risk for severe ulcerations after endoscopic outlet reduction interventions could be possible. The technique has a lot of benefits and shows a high safety in the literature. The potential risk of ulcera could be observed by follow up routine endoscopies. Optimizations in the field of patient selection, technical aspects like choice of the suture material, after treatment might be helpful to reduce the risk of such events.
Weight regain seems to be a frequent problem after Roux-en-Y gastric bypass (RYGB). When lifestyle interventions fail, further interventions get necessary. One of the key points in weight regain is the size of the gastrojejunal anastomosis. Re-sizing of a large anastomosis leads to a reduction of the pouch outlet. By this approach, the function of the bypass shall be restored. Beneath revision surgery, the transoral endoscopic outlet reduction is a powerful tool which has shown a high efficiency and safety in different studies.
Methods, Cases and Literature
Two patients with perforated marginal ulcers after endosurgery for weight regain had to be operated in a tertiary center in Switzerland last year. Both had secondary endoscopic reduction 8 respectively 12 years after a RYGP. The perforations happened 6 months respectively 2 years after the intervention. Other risk factors where previous ulcer in one case and short-term NSAID medication in the other. Both were female, 44 and 66 years old. They showed a generalized peritonitis and were treated in an emergency setting. After laparoscopic exploration and lavage an open repair with single stitch suturing, absorbable sutures, PDS 4.0 was performed. In one case, a suture from the Apollo System with its anchor was found in the perforation. Short-term antibiotic therapy and PPI where initialized. Pathology in both cases revealed transmural necrosis, no Helicobacter. Both recovered well, had a follow up endoscopy with a showed no further ulcer and proper healing of the mucosa.
So far, we found no description of a higher incidence of ulcer or even perforations after these endoscopic procedures. After RYGB an incidence of 3-7% of marginal ulcer is reported. The major factors for the development are a triad of inflammation trough foreign body reaction, ischemia by damaged microcirculation and hyperacidity. Usually, the ulcers appear early after surgery with a mean at 12 months.
Conclusion:
In our cases there where many years between the RYGP and the ulcer. In theory, suturing at the gastrojejunostomy could induce an episode of inflammation by additional foreign material. A change in microcirculation by the inflammation or tension on the tissue is also possible. Based on these physiological considerations and on the history of these cases an elevated risk for severe ulcerations after endoscopic outlet reduction interventions could be possible. The technique has a lot of benefits and shows a high safety in the literature. The potential risk of ulcera could be observed by follow up routine endoscopies. Optimizations in the field of patient selection, technical aspects like choice of the suture material, after treatment might be helpful to reduce the risk of such events.
Introduction
Weight regain seems to be a frequent problem after Roux-en-Y gastric bypass (RYGB). When lifestyle interventions fail, further interventions get necessary. One of the key points in weight regain is the size of the gastrojejunal anastomosis. Re-sizing of a large anastomosis leads to a reduction of the pouch outlet. By this approach, the function of the bypass shall be restored. Beneath revision surgery, the transoral endoscopic outlet reduction is a powerful tool which has shown a high efficiency and safety in different studies.
Methods, Cases and Literature
Two patients with perforated marginal ulcers after endosurgery for weight regain had to be operated in a tertiary center in Switzerland last year. Both had secondary endoscopic reduction 8 respectively 12 years after a RYGP. The perforations happened 6 months respectively 2 years after the intervention. Other risk factors where previous ulcer in one case and short-term NSAID medication in the other. Both were female, 44 and 66 years old. They showed a generalized peritonitis and were treated in an emergency setting. After laparoscopic exploration and lavage an open repair with single stitch suturing, absorbable sutures, PDS 4.0 was performed. In one case, a suture from the Apollo System with its anchor was found in the perforation. Short-term antibiotic therapy and PPI where initialized. Pathology in both cases revealed transmural necrosis, no Helicobacter. Both recovered well, had a follow up endoscopy with a showed no further ulcer and proper healing of the mucosa.
So far, we found no description of a higher incidence of ulcer or even perforations after these endoscopic procedures. After RYGB an incidence of 3-7% of marginal ulcer is reported. The major factors for the development are a triad of inflammation trough foreign body reaction, ischemia by damaged microcirculation and hyperacidity. Usually, the ulcers appear early after surgery with a mean at 12 months.
Conclusion:
In our cases there where many years between the RYGP and the ulcer. In theory, suturing at the gastrojejunostomy could induce an episode of inflammation by additional foreign material. A change in microcirculation by the inflammation or tension on the tissue is also possible. Based on these physiological considerations and on the history of these cases an elevated risk for severe ulcerations after endoscopic outlet reduction interventions could be possible. The technique has a lot of benefits and shows a high safety in the literature. The potential risk of ulcera could be observed by follow up routine endoscopies. Optimizations in the field of patient selection, technical aspects like choice of the suture material, after treatment might be helpful to reduce the risk of such events.
Weight regain seems to be a frequent problem after Roux-en-Y gastric bypass (RYGB). When lifestyle interventions fail, further interventions get necessary. One of the key points in weight regain is the size of the gastrojejunal anastomosis. Re-sizing of a large anastomosis leads to a reduction of the pouch outlet. By this approach, the function of the bypass shall be restored. Beneath revision surgery, the transoral endoscopic outlet reduction is a powerful tool which has shown a high efficiency and safety in different studies.
Methods, Cases and Literature
Two patients with perforated marginal ulcers after endosurgery for weight regain had to be operated in a tertiary center in Switzerland last year. Both had secondary endoscopic reduction 8 respectively 12 years after a RYGP. The perforations happened 6 months respectively 2 years after the intervention. Other risk factors where previous ulcer in one case and short-term NSAID medication in the other. Both were female, 44 and 66 years old. They showed a generalized peritonitis and were treated in an emergency setting. After laparoscopic exploration and lavage an open repair with single stitch suturing, absorbable sutures, PDS 4.0 was performed. In one case, a suture from the Apollo System with its anchor was found in the perforation. Short-term antibiotic therapy and PPI where initialized. Pathology in both cases revealed transmural necrosis, no Helicobacter. Both recovered well, had a follow up endoscopy with a showed no further ulcer and proper healing of the mucosa.
So far, we found no description of a higher incidence of ulcer or even perforations after these endoscopic procedures. After RYGB an incidence of 3-7% of marginal ulcer is reported. The major factors for the development are a triad of inflammation trough foreign body reaction, ischemia by damaged microcirculation and hyperacidity. Usually, the ulcers appear early after surgery with a mean at 12 months.
Conclusion:
In our cases there where many years between the RYGP and the ulcer. In theory, suturing at the gastrojejunostomy could induce an episode of inflammation by additional foreign material. A change in microcirculation by the inflammation or tension on the tissue is also possible. Based on these physiological considerations and on the history of these cases an elevated risk for severe ulcerations after endoscopic outlet reduction interventions could be possible. The technique has a lot of benefits and shows a high safety in the literature. The potential risk of ulcera could be observed by follow up routine endoscopies. Optimizations in the field of patient selection, technical aspects like choice of the suture material, after treatment might be helpful to reduce the risk of such events.
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