Laparoscopic management of a perforated ulcer at the gastrojejunal anastomosis after LGBP

Anastomotic ulcers (also known as ‘‘marginal’’ ulcers) develop as a complication of Roux-en-Y gastric bypass for treatment of obesity, they are almost always found to arise in the jejunal Roux limb directly abutting the gastrojejunal anastomosis. Marginal ulcers have been reported in 1–16% of patients after gastric bypass surgery, developing in both the early and late postoperative periods. Recommended references: 1. Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–516. 2. Csendes A, Burgos AM, Altuve J, Bonacic S. 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. Obes Surg 2009;19:135–138. 3. Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009;5:317–322. 4. St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668. 5. Goitein D. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;13(6):880–882.

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LAPAROSCOPIC   MANAGEMENT   OF   A   PERFORATED   ULCER   AT   THE   GASTROJEJUNAL   ANASTOMOSIS   AFTER   LGBP

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Abstract
Anastomotic ulcers (also known as ‘‘marginal’’ ulcers) develop as a complication of Roux-en-Y gastric bypass for treatment of obesity, they are almost always found to arise in the jejunal Roux limb directly abutting the gastrojejunal anastomosis. Marginal ulcers have been reported in 1–16% of patients after gastric bypass surgery, developing in both the early and late postoperative periods.
Recommended references:
1. Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–516.
2. Csendes A, Burgos AM, Altuve J, Bonacic S. 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. Obes Surg 2009;19:135–138.
3. Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009;5:317–322.
4. St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668.
5. Goitein D. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;13(6):880–882.
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05'30''
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2011-12
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WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3497.htm

LAPAROSCOPIC   MANAGEMENT   OF   A   PERFORATED   ULCER   AT   THE   GASTROJEJUNAL   ANASTOMOSIS   AFTER   LGBP

5. Ulcer suturing 02'35''
The ulcer was sutured using an absorbable braided 2/0 thread. The jejunum just distal to the gastrojejunal anastomosis is bathed in this acid and, given that it does not have the acid buffering capability of the duodenum, it becomes vulnerable to ulcer formation. In addition, while prevention is key, it is often difficult to achieve. While most of these types of ulcers do respond to medical therapy, there is a select group of patients that continues to suffer from symptomatic, non-healing ulcers, despite appropriate medical treatment, and requires surgical intervention. For perforated marginal ulcer, diagnostic laparoscopy with repair has been found to be safe and successful, particularly in the first 24 hours of diagnosis and for patients without evidence of sepsis or hemodynamic instability. The first step is to perform a thorough investigation by mobilizing the remnant stomach, duodenum, and Roux limb to identify the source of perforation. Once identified, repair is performed by oversewing the perforation. Others advocate primary closure with absorbable suture, reinforcement with a gastrosplenic ligament patch and fibrin sealant, and closed-suction drain placement. If laparoscopic repair cannot be performed safely, the operative plan should be carried out in an open fashion. If primary closure is not possible, irrigation and drainage is the next appropriate approach. If ischemia is suspected as the cause of the perforated marginal ulcer, then complete reconstruction of the gastrojejunostomy is indicated.