Truncal Vagotomy and Gastrojejunostomy Revision for Treatment of Marginal Ulcer.

Background: Marginal ulcer (MU) remains a serious complication after Roux-en-Y gastric bypass (RYGB). This can be a life-threatening problem, even years after RYGB. Patients can present with pain or even with hemorrhage or perforation. There is no agreed-upon standard in prevention or treatment, although most perforated ulcers are treated with an omental patch. We present our results of treatment of MU with truncal vagotomy (TV).

Methods: A retrospective chart review identified patients who required surgical intervention for nonhealing MU or those presenting with perforated MU. Free perforation was treated with surgical intervention at the time of presentation. In patients with recalcitrant MU (without perforation), preoperative upper endoscopy confirmed the diagnosis. In all cases, the gastrojejunal anastomosis was revised or the marginal ulcer was resected, followed by laparoscopic TV. We reviewed operative time, ulcer recurrence, and complications in the cases identified.

Results: Forty-two patients underwent revision/resection following presentation with a recalcitrant ulcer or free perforation of a MU. Concomitant TV was performed in all cases. Average time from the RYGB was 71.8 months. There were no 30-day mortalities and no leaks. Average follow-up was 21 months. Sixty-two percent of patients had a follow-up endoscopy by 1 year with no recurrences. There were no reoperations or major complications.

Conclusion: Marginal ulceration remains a common complication after Roux-en-Y gastric bypass. Medical therapy is the first-line therapy but some patients will go on to develop refractory disease. This can be chronic, or acute with perforation or hemorrhage. Laparoscopic truncal vagotomy with revision of the gastrojejunal anastomosis is safe and effective in the treatment of marginal ulcers with low recurrence rates.