3. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
1. Low Risk
2. Major Weight Loss
3. Easily performed
4. Short operative times
5. Outpatient or short hospital stay
6. Minimal Blood Loss
7. No Need for ICU Stay
8. Minimal Pain
9. Very High Patient Satisfaction
10. A Good "Exit Strategy"
4. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
11. Change Behavior & Preferences; Marked Decrease in
Hunger and Increased Satiety
12. Minimal Retching and Vomiting
13. Few adhesions or hernias
14. Minimal impact on Heart and Lung Function
15. Low Failure Rate
16. Low Cost
17. Short Recovery Time
18. Rapid Return to Work
19. Low Risk of Pulmonary Embolus
20. Durable weight loss
5. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
21. Low Risk of Marginal Ulcer
22. Fat Malabsorption; low cholesterol & CV risk
23. No Plastic Foreign Body
24. Easily Verifiable Results; > 10 years of Results
25. Low Risk of Bowel Obstruction
26. Based upon sound surgical principles
27. Independent confirmation of results
28. Healthy life after surgery
29. Supported by LEVEL I Evidence; RCT (Controlled
Prospective Randomized Trial)
30. Block “Sweet Eater” Failures
11. Epidemiology: What do we know about
Marginal Ulcers?
Marginal ulcers represent one of the most problematic
postoperative complications following Roux-en-Y
A marginal ulcer, or stomal ulceration, refers to the
development of mucosal erosion at the gastrojejunal
anastomosis, typically on the jejunal side.
incidence of marginal ulcers is 0.6 to 16 %
The true incidence is very likely much higher
12. Marginal Ulcer has been known since the
beginning GI Surgery
MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER
SUBSEQUENT TO GASTROENTEROSTOMY.
Erdmann JF.
Ann Surg. 1921 Apr;73(4):434-40.
13. Marginal Ulcer has been known since the
beginning GI Surgery
THE ROENTGEN DIAGNOSIS AND LOCALIZATION
OF MARGINAL PEPTIC ULCER.
Carman RD.
Cal State J Med. 1920 Nov;18(11):377-82
14. Marginal Ulcer has been known since the
beginning GI Surgery
Re-evaluation of the role of the pyloric antrum in
marginal peptic ulcers.
SCHILLING JA, PEARSE HE.
Surg Gynecol Obstet. 1948 Aug;87(2):225-34
15. Marginal Ulcer has been known since the
beginning GI Surgery
Vagotomy as a treatment for marginal ulcer.
CRILE G Jr, BROWN GM Jr.
Gastroenterology. 1951 Jan;17(1):14-9
16. Marginal Ulcer has been known since the
beginning GI Surgery
Review Article: The present status of the management
of marginal ulcer.
BYRD BF Jr.
J Tn State Med Assoc. 1953 Feb;46(2):56-8.
17. Marginal Ulcer has been known since the
beginning GI Surgery
2,282 RYGB
122 (5%) Marginal ulcers
39 (32%) Surgery
Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal ulcer
after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University
Medical Center at Princeton, Princeton, New Jersey 08536
18. Marginal Ulcer Very High After RNY Gastric
Bypass
441 RYGB
10 (12%) of RNY gastric bypass presented an "early"
marginal ulcer
Asymptomatic (28%)
Obes Surg. 2009 Feb;19(2):135 Incidence of marginal ulcer 1 month and 1 to 2 years after
gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid
obesity. Csendes A et al Department of Surgery, University Hospital, University of Chile,
Santiago, Chile.
19. Marginal Ulcer Very High After RNY Gastric
Bypass
Associated with H. Pylori
260 RYGB
7% of RNY gastric bypass marginal ulcer
H. pylori infection, (treated), was twice as common
marginal ulceration (32%) as among those who did not
(12%)
Surg Endosc. 2007 Jul;21(7):1090-4. Marginal ulceration after laparoscopic gastric bypass:
an analysis of predisposing factors in 260 patients. Rasmussen JJ, Department of Surgery,
University of California, Davis, 2221 Stockton Boulevard, Sacramento, CA 95817, USA
20. Marginal Ulcer after Gastric Bypass;
Both RNY & MGB
Marginal Ulcers after Roux-en-Y Gastric Bypass:
Pain for the Patient…Pain for the Surgeon
by Camellia Racu,
January 2010
Bariatric Times.
2010;7(1):23–25
22. Marginal Ulcer after Gastric Bypass;
RNY & MGB
Marginal ulcers RNY ranging from 0.6 to 16%
True incidence is very likely much higher
Csendes prospective study
routine postoperative endoscopic evaluation
28% of marginal ulcers were asymptomatic
Gastric Bypass (RNY & MGB)
HIGH incidence of Marginal Ulcer
BILE MAKES NO DIFFERENCE!!!
23. Incidence of perforated gastrojejunal
anastomotic ulcers after RNY
April 2002 to April 2010, 1213 patients underwent
laparoscopic RYGB
Operative mortality was .15%
10 perforated GJA ulcers (.82%) at a mean of 13.5
(6-19) months
Morbidity and mortality rate was 30% and 10%
Perforated GJA ulcers can develop in 1 of 120 Roux
en Y Gastric Bypasses & DEADLY
24. Marginal Ulcers:
Achilles Heel of Gastric Bypass
Management
1. Warn Patients & Surgeon “Be Vigilant”
2. Aggressive anti-H. Pylori Rx
3. Aggressive use of Antacids
4. Strict Avoidance of Ulcerogenic Agents
(NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates)
5. Encourage: Probiotics, Yogurt, Fruits Vegetables
BILE MAKES NO DIFFERENCE!!!
25. CONCLUSIONS:
Best Choice: Mini-Gastric Bypass
•Choice of Obesity Surgery
•Objectives “Ideal” Weight Loss Surgery
•RNY, Band, Sleeve, MGB
•MGB Best meets all objectives/success criteria
•Beware of Marginal Ulcer in RNY & MGB
•Rational Decision Making:
Best Choice; Mini-Gastric Bypass