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.

BACKGROUND: Marginal ulcer (MU) is an occasional complication after gastric bypass. We studied the incidence of this complication by a prospective routine endoscopic evaluation.
METHODS: 441 morbidly obese patients were studied prospectively. There were 358 women and 97 men, with mean age 41 years and mean BMI 43 kg/m(2). An endoscopic evaluation was performed in all 1 month after surgery, which was repeated in 315 patients (71%) 17 months after surgery, independent of the presence or absence of symptoms. Patients were submitted either to laparotomic resectional gastric bypass (360 patients), employing a circularstapler-25 or to laparoscopic gastric bypass (81 patients), in whom a hand-sewn anastomosis was performed.
RESULTS: One month after surgery, 15 patients (4.1%) of the 360 laparotomic gastric bypass and 10 (12.3%) of the 81 laparoscopic gastric bypass presented an "early" marginal ulcer (p < 0.02). Seven patients among the 25 with MU were asymptomatic (28%). Endoscopy was repeated 17 months after surgery. Among 290 patients with no early MU, one patient (0.3%) presented a "late" MU 13 months after surgery. From the 25 patients with "early" MU, one patient (4%) presented a "late" MU. All these patients were treated with PPIs.
CONCLUSION: By performing prospective routine endoscopic study 1 month and 17 months after gastric bypass, two different behaviors were seen regarding the appearance MU: (a) "early" MU, 1 month after surgery in mean 6% and (b) "late" MU, in a very small proportion of patients (0.6%). Among patients with "early" MU, those who had undergone resectional gastric bypass showed significantly less ulcers compared to those patients in whom the excluded distal gastric segment had been left in situ. The operative method may play a significant role in the pathogenesis of MU after gastric bypass.