Management of Anastomotic Ulcers After Roux-en-Y Gastric Bypass: Results of an International Survey

Steinemann, Daniel ; Bueter, Marco ; Schiesser, Marc ; Amygdalos, Iakovos ; Clavien, Pierre-Alain ; Nocito, Antonio

In: Obesity Surgery, 2014, vol. 24, no. 5, p. 741-746

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    Background: Anastomotic ulcers (AUs) after Roux-en-Y gastric bypass (RYGB) occur in up to 16% of patients. In an international survey among members of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), current preventative and therapeutic strategies in AU were analyzed. Methods: An Internet-based survey was performed. Results: One hundred eighty-nine surgeons completed the survey. Preoperative screening for Helicobacter pylori is performed by 65%. Eighty-eight percent of them prophylactically prescribe antacids for 3months after surgery (interquartile range (IQR) 1-6). In case of AU, 99% of participants opt for proton pump inhibitors (PPIs) either alone (60%) or in combination with sucralfate (39%). After ulcer resolution, 52% continue PPI for 6 (3-6) months. In case of AU recurrence, 56% continue with conservative treatment. In contrast, 41% of them favor a renewal of the gastrojejunal anastomosis either combined with truncal vagotomy (18%) or with gastric remnant resection (13%), and only 2% choose to resect both gastric pouch and gastric remnant with subsequent reconstruction by esophagojejunostomy. In case of recurrence after surgical revision, 46% of participants opt again for a conservative approach, while 36% chose to redo the gastrojejunostomy once again. Conclusions: The majority of bariatric surgeons recommend preoperative screening and eradication of H. pylori as well as prophylactic use of PPI. If an AU is diagnosed, the role of PPI as a first-line treatment seems to be undisputed. However, dosage and duration of therapy remain unclear. In refractory AU, there is no consensus among bariatric surgeons whether conservative treatment or surgical revision should be performed.