Marginal ulcers after Roux Y gastric bypass has been reported to be between 0.6 to 16%

• The overall incidence has been reported to be 11.4% (after 8 years follow up)

Marginal ulcers can also be found in one anastomosis gastric bypass (reported 0.5 to 8%), BPD-DS (duodenal switch) (reported 1.3% per year with 6 years follow up study) and SADI-S

• The magnitude of the risk for marginal ulcer has not been shown to be different than that for RYGBP

The risk of marginal ulcer is highest immediately after gastric bypass surgery and decreases with time but never drops to zero

• Most gastric ulcers are diagnosed within the first year (8-14 months after surgery)

Prophylactic anti acid medications proton pump inhibitors (PPI) for at least 3 months significantly reduces the risk for marginal ulcer however the optimal duration remains a debate

• The role of Helicobacter pylori (HP) in marginal ulcer is not clearly defined, currently there are no recommendations from the metabolic and bariatric surgical societies on pre-op eradication of HP
• Larger gastric pouch may increase the risk for marginal ulcer
• Circular staple anastomosis and the use of non absorbable suture material increase the risk for marginal ulcers
• Patient factors that increases the risk for marginal ulcers include cigarette smoking, vaping, the use of non steroidal anti-inflammatory tablets (NSAIDs), immunosuppressant, Type 2 diabetes mellitus, peripheral vascular disease

Smoking increases the risk for marginal ulcer by 4.6 fold regardless of the quantity (even for those who smoke <10/day)

One study reported that 65% of their patients resumed smoking after RYGBP and 51% of these patients develop marginal ulcers

• For those who did not resume smoking, 15% develop marginal ulcer
• For those who never smoked, 6% develop marginal ulcer

Immunosupression and NSAIDs has a reported 6.9% marginal ulcer rate after 24months of follow up

• Immunosupression has 4.6 fold increased risk for ulcer
• NSAIDs has 3.1 increased risk for ulcer

For patients who smokes or recently quit the gastric bypass is not recommended   For patients on immunosuppression or takes NSAIDs regularly, the gastric bypass may not be the bariatric surgery of choice

Marginal ulcer symptoms and management   Currently there is little evidence to support screening for gastric ulcers routinely after gastric bypass   Gastroscopy is usually performed for patients with abdominal symptoms   The symptoms of gastric ulcer include abdominal pain, dysphagia, poor appetite, nausea and vomiting (but symptoms does not correlate well with marginal ulcer) Complications of ulcers include bleeding, perforation and gastro-gastric fistula       The management of uncomplicated ulcers include cessation of cigarette smoking, non steroidal anti inflammatory tablets, immunosuppressant medications, eradication of Helicobacter pylori and endoscopic removal of any foreign body staple material   Proton pump inhibitors (PPI) with Sucralfate medication is usually given +/- H2 receptor antagonist *The duration of treatment varies between 3 months to 2 years, some patients remain on PPI medication for life *The treatment success rate of uncomplicated ulcers has been reported to be between 67 to 100%       The management of complicated ulcers often require surgery *It has been reported that 9.3% of marginal ulcers after RYGBP require surgery and these ulcers tend to recur despite revision surgery *The estimated cumulative incidence of marginal ulcer recurrence is 15% (at 6 months) and 24% (at 12 months) post ulcer revision surgery *Another study reported 9% of patient with ulcer require surgery including revision of the gastro-jejunostomy *Even patients who quit smoking 1 year after the gastric bypass also had a higher risk for revision surgery for ulcers (5.7%) compared to patients who quit smoking less than 1 year before the gastric bypass (15.9%)

Bleeding Up to 24% of marginal ulcers can bleed with haematemesis, melena, haematochezia or iron deficiency anaemia   Higher risk in patients who has anti platelet and anti coagulation tablets   Management options: *Reversal of these medications followed by endoscopic treatment *Recurrent bleeding ulcers may require angiographic embolization or surgical revision of the gastro-jejunostomy *Bleeding splenic artery pseudoaneurysm and aorto-enteric fistula is rare and may be potentially fatal

Perforation Perforation of the marginal ulcer may occur even in previously asymptomatic patients *The incidence has been reported to be between 0.44 to 1% after RYGBP *After developing marginal ulcers about 20-23% of patients will present with perforation   Apart from cigarette or NSAIDs use, patients with peripheral vascular disease, renal failure and other drug abuse are the highest risk for perforation of the gastric ulcer     Management is urgent resuscitation and surgery for the perforated ulcer and treatment of the peritonitis/sepsis   The repair of the ulcer usually entails an omental patch for the mucosal defect and feeding tube to the bypassed stomach of the Roux Y   Patients with persistent leak after the initial ulcer repair include total parenteral nutrition (TPN) or distal enteral feeding tube   For the RYGBP patients, some may require revision surgery of the gastro-jejunostomy or even complete reversal of the gastric bypass     For the one anastomosis gastric bypass, the marginal ulcer perforation rate has been reported to be 0.8% *Surgical management options and suggestion include conversion to RYGBP or Braun anastomosis (side to side jeunjejunostomy) to divert the bile and pancreatic secretions away from the site of the perforation at the gastric anastomosis   *For hostile abdomen a T tube catheter may be inserted into the ulcer perforation site with external drainage

Stricture Stricture at the gastro-jejunostomy site has been reported to be around 3 to 27%   Anastomotic stricture are often due to marginal ulcer, which then produces excess scar tissue and obstruction or food intolerances   The primary management include endoscopic dilatation

Gastro-gastric fistula   Gastro-gastric fistula after gastric bypass is often due to marginal ulcers   Conservative management for small fistula <1cm includes cessation of cigarette smoking and NSAIDs, commence PPI medication + Sucralfate, endoscopic treatment (endoclips, sealant, oesophageal stents and endoscopic suturing) and mucosal edge ablation with APC   Surgical revision includes excision of the fistula and revision of the gastro-jejunostomy or complete reversal of the gastric bypass

Refractory marginal ulcers   Refractory marginal ulcer often require surgery (after 3 months of failed medical treatments or after 6 to 12 months of failed medical therapy)   Treatment options include endoscopic (suturing and stents) and this may take 8 weeks for the treating ulcer to heal   Surgical therapy include resection of the gastro-jejunostomy, the ischemic/ulcerated tissue and creation of a new gastro-jejunostomy +/- reduction of the gastric pouch, resection of the bypassed stomach remnant or truncal vagotomy *Another option is resection of the gastric pouch and creation of the oesophago-jejunostomy   Despite revision surgery another recurrent gastric ulcer can still recur     Complete reversal of the gastric bypass or conversion to a sleeve gastrectomy has been described These are technically challenging operations with a high complication risk, reported up to 29%