Revisional operations for marginal ulcer after Roux-en-Y gastric bypass.

Background: Marginal ulcer is a potentially serious complication of Roux-en-Y gastric bypass (RYGB). This study reviewed 1 surgeon's experience with 39 revisional operations for intractable marginal ulcer after primary RYGB.

Methods: A total of 2282 consecutive patients underwent RYGB by 1 surgeon from 1984 to 2006, of which 1621 were open and 661 laparoscopic. The stomach was transected in laparoscopic RYGB and was left undivided in the open group. All revisions included ulcer excision, revision of the gastrojejunostomy with gastric transection as needed. Six patients underwent vagotomy.

Results: Of the 2282 patients, 122 (5.3%) developed marginal ulcers (88 and 34 from the open and laparoscopic group, respectively). Of these 122 patients, 39 (32%) underwent revision for intractability (35 open and 4 laparoscopic). Of these 39 patients, 28 (71.7%) had gastrogastric fistulas. Risk factors for ulcer (medication, smoking) were present in 26 patients (66.6%). The primary indications of intractability included abdominal pain (66.6%), gastrointestinal bleeding (20.5%), stomal obstruction (10.2%), and perforation (2.5%). Early postoperative complications included 2 leaks (5.1%) and 2 wound infections (5.1%). Three smokers (7.7%) developed recurrent ulcers postoperatively. One patient died of acute respiratory distress syndrome 5 months postoperatively. Of the 39 patients, 34 (87%) remained asymptomatic after revision. The revision rate was significantly less after laparoscopic RYGB (.6%) than after open RYGB (2.1%; P < or =.0025).

Conclusion: The results of our study have shown that operations for intractable marginal ulcer after RYGB are highly successful in nonsmokers. Patients who undergo laparoscopic RYGB with gastric transection are less likely to require revision than patients who undergo RYGB with an incontinuity gastric partition. The rate of reoperation for marginal ulcer was greater than anticipated.