Endoscopic Management of Complications After Gastrointestinal Weight Loss Surgery

Nitin Kumar; Christopher C. Thompson

Disclosures

Clin Gastroenterol Hepatol. 2013;11(4):343-353. 

In This Article

Ulcer

Ulceration is the most common endoscopic finding in patients with abdominal pain.[13] Ulceration at the GJA is a common late complication after RYGB, occurring in approximately 20% of patients.[14] These most commonly develop in the first 3 months postoperatively but can occur at any time. Patients often present with epigastric pain, nausea, vomiting, food intolerance, and overt or occult bleeding.

Ulcers can present on the gastric side or the jejunal side of the anastomosis. Ulcers on the jejunal side may be a result of ischemia, overproduction of acid, or coexisting gastrogastric fistula. Anastomotic ulcers may be a result of bile acid reflux, pouch orientation and size, tension on the Roux limb, Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, smoking, or foreign body such as nonabsorbable sutures.[14,15–17] Gastrogastric fistula and staple line disruption may result in ulceration caused by acid exposure. The jejunum is particularly vulnerable because the pH buffering function of the duodenum has been lost. Preoperative H pylori infection is associated with postoperative anastomotic ulceration; it is possible that preexisting mucosal damage may result in ulceration even after eradication.[18] An analysis for risk factors found that predictors of anastomotic ulcer include smoking (adjusted odds ratio, 30.6) and NSAID use (adjusted odds ratio, 11.5).[19] A multivariable analysis found that diabetes (odds ratio, 5.6) was also associated.[15] Surgical risk factors include use of a circular stapler technique rather than a hand-sewn or linear stapler.[20,21] Chronic irritation by staples or sutures may also play a role; absorbable sutures are associated with a significantly lower rate of ulceration.[22]

Diagnosis

Investigation for anastomotic ulcer in the first 2 weeks postoperatively may be performed with Gastrografin to avoid stomal disruption during endoscopy; however, endoscopy can be safely performed. Endoscopic visualization should include the gastric pouch, GJA, and proximal Roux limb. Size, depth, and potential etiologic factors should be noted for each ulcer. Aspiration of the fluid in the gastric pouch should be performed before entering the jejunum; if the pH is neutral or alkaline, sucralfate may be used, but acid suppression may not be helpful.[23] H pylori breath testing and pouch biopsies may not be reliable; serology may be better to detect infection and fecal antigen to confirm eradication.[24,25]

Management

Treatment of ulceration should be directed by suspected etiology. In patients with RYGB, anastomotic ulcers should be treated with soluble proton pump inhibitors or capsules broken open taken twice daily and tapered over 6 months. Sucralfate solution at 1 g 4 times daily should be used concurrently when possible.[18] The tablet form is not effective. Bile reflux can be treated with bile acid binders such as cholestyramine or colestipol. Smoking cessation is critical. Control of diabetes should be optimized. NSAIDs should be discontinued if possible or combined with proton pump inhibitors or prostaglandin E1 therapy if needed long-term. Although ulcers in patients with high Roux limb tension usually resolve spontaneously, those associated with large pouch warrant acid suppression. Gastrogastric fistulas should be closed when present, and patients should be maintained on proton pump inhibitors to decrease acid exposure.[26] Visible nonabsorbable sutures should be extracted when possible.[27,28] Patients with LAGB may benefit from partial deflation; if the band erodes, it must be removed.

Healing should be assessed with repeat endoscopy. Persistent ulcers should prompt a search for gastrogastric fistula with upper gastrointestinal series because this may detect a fistula not seen on prior endoscopy.[14] Anastomotic ulceration may result in stricture formation at the GJA. Perforation is rare and often occurs in patients with active tobacco, NSAID, or steroid use.[29] Persistent deep ulcers may require surgical revision to prevent these complications.

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