Endoscopic Therapy for Bleeding Marginal Ulcers After Gastric Bypass
Condition: Bleeding Marginal Ulcer
MeSH terms: Peptic Ulcer; Ulcer; Hemorrhage
Study type: Observational

Summary: 
      The objective of this study is to identify the incidence rate; describe the risk factors,
      clinical presentation, and endoscopic treatment; assess the morbidity, mortality, and overall
      performance of the management of patients with actively bleeding marginal ulcers after
      Roux-en-Y gastric bypass (RYGB) surgery.
    

Detailed description: 
      Marginal ulceration "MU", which presents as an ulcer at the margins of the gastrojejunostomy
      on the jejunal side, is a common late complication after RYGB. Its incidence after RYGB
      ranges from as low as 0.6 to as high as 16%. In our hands with the laparoscopic hand-sewn
      technique for the GJ, the incidence is 1.4%. The presence of specific technical factors -
      staple-line dehiscence or gastro-gastric fistula, enlarged pouch, foreign material and local
      ischemia - and environmental factors - tobacco, NSAID´s, alcohol consumption, and H pylori
      infection among others - have been associated with marginal ulceration however the exact
      etiopathogenesis has not been completely elucidated.

      Similar to peptic ulcer disease (PUD), most marginal ulcers respond to medical therapy,
      specifically sucralfate and acid-lowering medication. In contrast, complicated marginal
      ulcers - perforation, bleeding, or chronicity (obstruction, penetration, and intractability)-
      warrants operative intervention.

      Early presentation of hemorrhage after RYGB is mostly related to staple-line failure and may
      result in either GI or intraabdominal hemorrhage. When indicated, operative interventions
      consist of either endoscopic therapy, re-operation, or both. In contrast, late presentation
      of gastrointestinal hemorrhage after RYGB is mostly secondary to a bleeding marginal ulcer
      however complicated peptic ulcer disease can present in the excluded stomach and duodenum as
      well.

      Most literature available for the management of GI hemorrhage after RYGB is for the early
      presentation of hemorrhage secondary to staple-line failure. Hence, options for endoscopic
      hemostatic therapy described in this scenario are I) injection therapy, II) coagulation
      therapy, III) endoscopic clipping, and IV) a combined modality (for example injection &
      coagulation or injection and clipping).

      The feasibility, reliability, reproducibility, efficacy, validity and safety of the
      endoscopic hemostatic therapy for acutely bleeding peptic ulcers has been well documented.
      Multiple risk-stratification tools for upper-GI hemorrhage have also been developed such as
      the Blatchford, clinical and complete Rockall scores, and the Forrest classification.
      Moreover, pre and post endoscopic schemes of PPI´s therapy in patients with bleeding peptic
      ulcers is effective and cost-saving. However, All of them have not been validated in the
      obese population status post RYGB complicated with a bleeding marginal ulcer.

      Summarizing, there is scant information about the management of late complications after
      gastric bypass especially after the widespread adoption of the laparoscopic approach and the
      modern anatomical construct of Roux-en-Y Gastric Bypass surgery. We formally analyze the
      management efficacy of patients with actively bleeding marginal ulcers after Roux-en-Y
      gastric bypass (RYGB) surgery.
    

Observational model: Cohort
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Patients with actively bleeding marginal ulcers after Roux-en-Y gastric bypass (RYGB)
        surgery.
      
Keywords: complicated marginal ulcer; complex marginal ulcer; complication after gastric bypass; gastrointestinal hemorrhage