Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review.

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.