- Email: [email protected]
Endoscopic suture removal at gastrojejunal anastomosis after Roux-en-Y gastric bypass to prevent marginal ulceration
Surgery for Obesity and Related Diseases 3 (2007) 619 – 622
Original article
Endoscopic suture removal at gastrojejunal anastomosis after Roux-en-Y gastric bypass to prevent marginal ulceration Eldo E. Frezza, M.D., M.B.A., F.A.C.S.a,*, Haleigh Herbert, B.S.a, Ronny Ford, M.D.a, Mitchell S. Wachtel, M.D.b b
a Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas Department of Pathology, Texas Tech University Health Sciences Center, Lubbock, Texas Received May 4, 2007; revised June 22, 2007; accepted August 24, 2007
Abstract
Background: After Roux-en-Y gastric bypass (RYGB) surgery, marginal ulcers develop in 3–23% of patients. Marginal ulcers can occur secondary to the use of nonabsorbable sutures to create the gastrojejunostomy. The suture can elicit a foreign body reaction that exposes it to the gastric lumen, irritating the mucosa. Surgical removal is mandated when medical therapy fails to resolve matters. Because endoscopic removal would be less invasive than laparotomy, a technique for the endoscopic removal of the suture was devised. Presented are the results of 6 patients who underwent this procedure. Methods: A computer search of all patients who had undergone laparoscopic RYGB was done and found 6 women who had undergone endoscopic suture removal. After a double-lumen endoscope was inserted through the mouth, a grasper was used to placed the suture under tension before transecting it with blunt-tip endoshears. The suture was then removed without difficulty. All patients were evaluated at 2 weeks and 6 months postoperatively. Results: Of the patients who underwent laparoscopic RYGB between June 2003 and June 2005 and presented with epigastric pain, 6 women underwent endoscopic stitch removal. These women had a mean age of 57 years, a mean initial body mass index of 55 kg/m2, and had undergone laparoscopic RYGB a mean of 18 months before presentation. The patients, who had experienced new-onset epigastric pain and “heartburn,” underwent endoscopic examination of the stomach, which showed visible suture at the gastrojejunal anastomosis, no ulceration, and edema, and underwent suture removal. No complications developed. At 6 months of follow-up, all patients were without symptoms and had normal findings on upper endoscopy. Conclusion: The results of our study have shown that endoscopic suture removal is a feasible and effective means of treating epigastric pain and preventing the suture-induced marginal ulcers that can occur after RYGB. (Surg Obes Relat Dis 2007;3:619 – 622.) © 2007 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Gastric bypass; Morbid obesity; Nonabsorbable suture; Gastrojejunal anastomosis; Marginal ulceration; Stenosis; Bleeding; Therapeutic algorithm
Roux-en-Y gastric bypass (RYGB) [1], one of the most common bariatric procedures, has various potential complications [2–7], including marginal ulceration in 3–23% of cases [3,8]. One potential cause of marginal ulcer formation *Reprint requests: Eldo E. Frezza, M.D., M.B.A., F.A.C.S., Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, 3502 9th Street, Suite 380, Lubbock, TX 79415. E-mail: [email protected]
is the use of nonabsorbable suture to create the gastrojejunostomy (GJ), which can elicit a foreign body reaction that exposes the suture to the gastric lumen, physically insulting the mucosa [5,9] (Fig. 1). When medical management fails, surgical exploration is necessary [4 –12]. Endoscopic suture removal is preferable to exploratory surgery. We present a series of 6 patients who underwent stitch removal after RYGB during the past 4 years and our algorithm for when patients present with signs or symptoms of epigastric pain.
1550-7289/07/$ – see front matter © 2007 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2007.08.019
620
E. E. Frezza et al. / Surgery for Obesity and Related Diseases 3 (2007) 619 – 622
Fig. 3. Sutures at GJ were easily removed.
Fig. 1. Presence of stitches, foreign body at GJ anastomosis.
Methods After institutional review board approval, a computer search of all patients who had undergone laparoscopic RYGB (LRYGB) was done and found 6 women who had undergone endoscopic stitch removal. We retrospectively reviewed the 6 patients diagnosed with an abnormal suture at the GJ after undergoing LRYGB. All 6 patients had undergone LRYGB 18 ⫾ 4 months before presentation. Upper endoscopy (esophagogastroduodenoscopy [EGDS]) was performed on all patients who presented with epigastric symptoms (n ⫽ 20). Only 6 patients required stitch removal. All patients were given a prophylactic proton pump inhibitor (PPI). We used a 38F Pentax endoscope (Pentax Medical, Montvale, NJ), with double-lumen interventional ports that allow for the use of both a 2-mm grasper and a 2-mm scissor simultaneously. The patients were placed under general anesthesia. After oral insertion of the endoscope and visualization of the stitches (Fig. 1), a grasper was used to placed the suture under tension (Fig. 2), before it was
transected with blunt-tip endoshears. The sutures at the GJ were then easily removed (Fig. 3), after which the mucosa was inspected for injury. All patients were clinical evaluated at 2 weeks postoperatively and underwent upper gastrointestinal endoscopy at 6 months postoperatively. Results Between June 2001 and June 2004, 211 patients underwent LRYGB. All the patients were given deep venous thrombosis prophylaxis before LRYGB, as previously reported [13], and LRYGB was performed as described previously [14]. The GJ anastomosis was created with 2.0 Surgidac (U.S. Surgical, Norwalk, CT). The mean body mass index of the 211 patients was 49 kg/m2 (range 38 – 65), and their average age was 48 years (range 29 – 60; Table 1). The complications after LRYGB included obstruction requiring operative management in 3% and leak requiring reoperation and drainage in 2 patients. One patient had undergone conversion to open surgery because of the presence of thick adhesions. Twenty patients presented with new-onset epigastric pain and “heartburn.” All 20 underwent endoscopic examination of the stomach, and only 6 had visible suture at the GJ anastomosis but no ulceration. Thus, of the 20 patients
Table 1 Patient demographics
Fig. 2. Grasper used to placed suture under tension before transecting it with blunt-tip endoshears.
Patients (n) Age (y) Mean Range BMI (kg/m2) Mean Range Complications Excess weight loss (%) BMI ⫽ body mass index.
211 48 29–60 48 38–65 0 63
E. E. Frezza et al. / Surgery for Obesity and Related Diseases 3 (2007) 619 – 622 Table 2 Factors associated with ulcer formation present in 6 women with stitch removal Pt. No.
Smoking
1 2 3 4 5 6
X
NSAID
ASA
X
X
Pt. No. ⫽ patient number; NSAID ⫽ nonsteroidal anti-inflammatory drug; ASA ⫽ acetylsalicylic acid.
who presented with epigastric symptoms, 6 women (2.8%) were diagnosed with nonabsorbable foreign body-like sutures at the GJ. These women had undergone LRYGB a mean of 18 ⫾ 4 months before their foreign body presentation. Their mean age was 57 years, and their mean initial body mass index was 55 kg/m2. Their percentage of excess weight loss was 63% at 2 years. At their 6-month follow-up visit, all 6 patients lacked symptoms and underwent follow-up endoscopy that showed the absence of ulceration and erosion. No intraoperative complications were reported. The factors associated with the development of an ulcer are reported in Table 2. Discussion Marginal ulceration, a known complication of RYGB, can be managed medically [4,6], but sometimes requires surgery [4,10]. Marginal ulcers have been associated with nonabsorbable suture that has been “rejected,” creating a foreign body reaction [5]. Once identified, it is our position that visible sutures at the GJ anastomosis should be removed. Using a double-lumen endoscope, we were able to successfully retrieve visible sutures in all 6 patients. These 6 women, with suture-induced symptoms, experienced resolution of their problem after this simple endoscopic procedure. The patients had no observable immediate or shortterm complications. This would suggest that the mechanical effects of a foreign body at the GJ contributed to the potential ulceration at the GJ after RYGB built with nonabsorbable stitches, as described previously [4,6,11,12,14]. Another cause of marginal ulceration is local ischemia. However, a definite consensus has not yet been reached regarding this, because some clinical studies have shown that it is related to the use of nonsteroidal anti-inflammatory drugs [5,14] and others have reported that the phenomena is secondary to the decrease in endogenous prostaglandin synthesis that is usually the protector of the gastric mucosa [15]. As a result, some investigators have switched to absorbable sutures, which has reduced the rate of both marginal ulceration and suture rejection and the risk of hemorrhage [5,11,16,17]. Marginal ulceration should always be treated because of the risk of hemorrhage [18]. Bleeding has been
621
reported secondary to marginal ulceration [17] and can occur several years after RYGB [19,20]. In our experience, we did not find any marginal ulceration or severe bleeding. This was probably because we performed early endoscopy as soon as the patients presented with symptoms of epigastric pain. All these patients were instructed to take a PPI before the endoscopic procedure for 3– 4 weeks, and they had complete relief of their pain even after the PPI was stopped. None of our patients had positive Helicobacter pylori findings, which has also been shown to be one of the causes, together with tobacco use, of marginal ulceration [11,17]. It will be advisable to study patients with and without PPI use, but, at present, not using a PPI is not the standard of care and would place the patient in danger. Our simple retrievable technique we have described provides a solution for those patients who experience problems after the use of nonabsorbable sutures. The 6-month follow-up examination was performed to check on the presence of other sutures, but it is not needed in asymptomatic patients. Endoscopy is required whenever a patient presents with questionable bleeding or epigastric pain, because it is needed to exclude stenosis and other complications of the initial surgery [19,21]. Fig. 4 illustrates our approach to this problem. Whenever patients present with epigastric pain or “heartburn,” we perform upper endoscopy to evaluate the stomach, esophagus, and intestine, with attention directed to the anastomotic line. Although an array of findings may be present at examination unrelated to the original operation, in general, one will find marginal ulceration, a stitch within a marginal ulcer, or stenosis. For marginal ulceration without a stitch present, we recommend a trial of medication. If this fails, reoperation or repeat EGDS with injection of epinephrine or another solution to control bleeding should be performed. For ulcers with the presence of a stitch, we suggested the algorithm we have outlined (Fig. 4). For stenosis, balloon dilation should be performed.
Fig. 4. Stepwise approach in patients complaining of epigastric pain after RYGB (GBP).
622
E. E. Frezza et al. / Surgery for Obesity and Related Diseases 3 (2007) 619 – 622
Conclusion Stitch removal can be easily performed endoscopically using the technique we have described. It should be a part of the armamentarium of surgeons who must evaluate patients who undergo EGDS after presenting with epigastric pain, bleeding, or difficulty eating after LRYGB.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
References [1] Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47–55. [2] Frezza EE, Wachtel MS. Laparoscopic re-exploration in mechanical bowel obstruction after laparoscopic gastric bypass for morbid obesity. Miner Chir 2006;61:193–7. [3] Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–16. [4] Marano BJ Jr. Endoscopy after Roux-en-Y gastric bypass: a community hospital experience. Obes Surg 2005;15:342–5. [5] Sacks BC, Mattar SG, Qureshi FG, et al. Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Rouxen-Y gastric bypass. Surg Obes Relat Dis 2006;2:11–16. [6] Dallal RM, Bailey LA. Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis 2006;2:455–9. [7] Szomstein S, Kaidar-Person O, Naberezny K, Cruz-Correa M, Rosenthal R. Correlation of radiographic and endoscopic evaluation of gastrojejunal anastomosis after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:617–21.
[8] Wilson JA, Romagnuolo J, Byrne TK, Morgan K, Wilson FA. Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol 2006;101:2194 –9. [9] St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668. [10] Gumbs AA. Incidence and management of marginal ulceration after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006; 2:460 –3. [11] MacLean LD. Stomal ulcer after gastric bypass. J Am Coll Surg 1997;185:1–7. [12] Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, Wolfe, L. Stomal complications of gastric bypass: incidence and outcome of therapy. Am J Gastroenterol 1992;87:1165–9. [13] Frezza EE, Wachtel MS. A simple venous thromboembolism prophylaxis protocol for patients undergoing bariatric surgery. Obesity 2006; 14:1961–5. [14] Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–29. [15] Kurata JH, Nogawa AN. Meta-analysis of risk factors for peptic ulcer: nonsteroidal anti-inflammatory drugs. Helicobacter pylori, and smoking. J Clin Gastroenterol 1997;24:2–17. [16] Cryer B. Mucosal defense and repair: role of prostaglandins is the stomach and duodenum. Surg Clin North Am 2001;30:877–94. [17] Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 1999;9: 22–7. [18] Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications. Lancet 2002;359:114 –7. [19] Braley SC, Nguyen NT, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2003;13:62–5. [20] Carrodeguas L, Szomstein S, Soto F, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 2005;1:467–74. [21] Huang CS, Forse RA, Jacobson BC, Farraye FA. Endoscopic findings and their clinical correlations in patients with symptoms after gastric bypass surgery. Gastrointest Endosc 2003;58:859 – 66.
Original article
Endoscopic suture removal at gastrojejunal anastomosis after Roux-en-Y gastric bypass to prevent marginal ulceration Eldo E. Frezza, M.D., M.B.A., F.A.C.S.a,*, Haleigh Herbert, B.S.a, Ronny Ford, M.D.a, Mitchell S. Wachtel, M.D.b b
a Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas Department of Pathology, Texas Tech University Health Sciences Center, Lubbock, Texas Received May 4, 2007; revised June 22, 2007; accepted August 24, 2007
Abstract
Background: After Roux-en-Y gastric bypass (RYGB) surgery, marginal ulcers develop in 3–23% of patients. Marginal ulcers can occur secondary to the use of nonabsorbable sutures to create the gastrojejunostomy. The suture can elicit a foreign body reaction that exposes it to the gastric lumen, irritating the mucosa. Surgical removal is mandated when medical therapy fails to resolve matters. Because endoscopic removal would be less invasive than laparotomy, a technique for the endoscopic removal of the suture was devised. Presented are the results of 6 patients who underwent this procedure. Methods: A computer search of all patients who had undergone laparoscopic RYGB was done and found 6 women who had undergone endoscopic suture removal. After a double-lumen endoscope was inserted through the mouth, a grasper was used to placed the suture under tension before transecting it with blunt-tip endoshears. The suture was then removed without difficulty. All patients were evaluated at 2 weeks and 6 months postoperatively. Results: Of the patients who underwent laparoscopic RYGB between June 2003 and June 2005 and presented with epigastric pain, 6 women underwent endoscopic stitch removal. These women had a mean age of 57 years, a mean initial body mass index of 55 kg/m2, and had undergone laparoscopic RYGB a mean of 18 months before presentation. The patients, who had experienced new-onset epigastric pain and “heartburn,” underwent endoscopic examination of the stomach, which showed visible suture at the gastrojejunal anastomosis, no ulceration, and edema, and underwent suture removal. No complications developed. At 6 months of follow-up, all patients were without symptoms and had normal findings on upper endoscopy. Conclusion: The results of our study have shown that endoscopic suture removal is a feasible and effective means of treating epigastric pain and preventing the suture-induced marginal ulcers that can occur after RYGB. (Surg Obes Relat Dis 2007;3:619 – 622.) © 2007 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Gastric bypass; Morbid obesity; Nonabsorbable suture; Gastrojejunal anastomosis; Marginal ulceration; Stenosis; Bleeding; Therapeutic algorithm
Roux-en-Y gastric bypass (RYGB) [1], one of the most common bariatric procedures, has various potential complications [2–7], including marginal ulceration in 3–23% of cases [3,8]. One potential cause of marginal ulcer formation *Reprint requests: Eldo E. Frezza, M.D., M.B.A., F.A.C.S., Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, 3502 9th Street, Suite 380, Lubbock, TX 79415. E-mail: [email protected]
is the use of nonabsorbable suture to create the gastrojejunostomy (GJ), which can elicit a foreign body reaction that exposes the suture to the gastric lumen, physically insulting the mucosa [5,9] (Fig. 1). When medical management fails, surgical exploration is necessary [4 –12]. Endoscopic suture removal is preferable to exploratory surgery. We present a series of 6 patients who underwent stitch removal after RYGB during the past 4 years and our algorithm for when patients present with signs or symptoms of epigastric pain.
1550-7289/07/$ – see front matter © 2007 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2007.08.019
620
E. E. Frezza et al. / Surgery for Obesity and Related Diseases 3 (2007) 619 – 622
Fig. 3. Sutures at GJ were easily removed.
Fig. 1. Presence of stitches, foreign body at GJ anastomosis.
Methods After institutional review board approval, a computer search of all patients who had undergone laparoscopic RYGB (LRYGB) was done and found 6 women who had undergone endoscopic stitch removal. We retrospectively reviewed the 6 patients diagnosed with an abnormal suture at the GJ after undergoing LRYGB. All 6 patients had undergone LRYGB 18 ⫾ 4 months before presentation. Upper endoscopy (esophagogastroduodenoscopy [EGDS]) was performed on all patients who presented with epigastric symptoms (n ⫽ 20). Only 6 patients required stitch removal. All patients were given a prophylactic proton pump inhibitor (PPI). We used a 38F Pentax endoscope (Pentax Medical, Montvale, NJ), with double-lumen interventional ports that allow for the use of both a 2-mm grasper and a 2-mm scissor simultaneously. The patients were placed under general anesthesia. After oral insertion of the endoscope and visualization of the stitches (Fig. 1), a grasper was used to placed the suture under tension (Fig. 2), before it was
transected with blunt-tip endoshears. The sutures at the GJ were then easily removed (Fig. 3), after which the mucosa was inspected for injury. All patients were clinical evaluated at 2 weeks postoperatively and underwent upper gastrointestinal endoscopy at 6 months postoperatively. Results Between June 2001 and June 2004, 211 patients underwent LRYGB. All the patients were given deep venous thrombosis prophylaxis before LRYGB, as previously reported [13], and LRYGB was performed as described previously [14]. The GJ anastomosis was created with 2.0 Surgidac (U.S. Surgical, Norwalk, CT). The mean body mass index of the 211 patients was 49 kg/m2 (range 38 – 65), and their average age was 48 years (range 29 – 60; Table 1). The complications after LRYGB included obstruction requiring operative management in 3% and leak requiring reoperation and drainage in 2 patients. One patient had undergone conversion to open surgery because of the presence of thick adhesions. Twenty patients presented with new-onset epigastric pain and “heartburn.” All 20 underwent endoscopic examination of the stomach, and only 6 had visible suture at the GJ anastomosis but no ulceration. Thus, of the 20 patients
Table 1 Patient demographics
Fig. 2. Grasper used to placed suture under tension before transecting it with blunt-tip endoshears.
Patients (n) Age (y) Mean Range BMI (kg/m2) Mean Range Complications Excess weight loss (%) BMI ⫽ body mass index.
211 48 29–60 48 38–65 0 63
E. E. Frezza et al. / Surgery for Obesity and Related Diseases 3 (2007) 619 – 622 Table 2 Factors associated with ulcer formation present in 6 women with stitch removal Pt. No.
Smoking
1 2 3 4 5 6
X
NSAID
ASA
X
X
Pt. No. ⫽ patient number; NSAID ⫽ nonsteroidal anti-inflammatory drug; ASA ⫽ acetylsalicylic acid.
who presented with epigastric symptoms, 6 women (2.8%) were diagnosed with nonabsorbable foreign body-like sutures at the GJ. These women had undergone LRYGB a mean of 18 ⫾ 4 months before their foreign body presentation. Their mean age was 57 years, and their mean initial body mass index was 55 kg/m2. Their percentage of excess weight loss was 63% at 2 years. At their 6-month follow-up visit, all 6 patients lacked symptoms and underwent follow-up endoscopy that showed the absence of ulceration and erosion. No intraoperative complications were reported. The factors associated with the development of an ulcer are reported in Table 2. Discussion Marginal ulceration, a known complication of RYGB, can be managed medically [4,6], but sometimes requires surgery [4,10]. Marginal ulcers have been associated with nonabsorbable suture that has been “rejected,” creating a foreign body reaction [5]. Once identified, it is our position that visible sutures at the GJ anastomosis should be removed. Using a double-lumen endoscope, we were able to successfully retrieve visible sutures in all 6 patients. These 6 women, with suture-induced symptoms, experienced resolution of their problem after this simple endoscopic procedure. The patients had no observable immediate or shortterm complications. This would suggest that the mechanical effects of a foreign body at the GJ contributed to the potential ulceration at the GJ after RYGB built with nonabsorbable stitches, as described previously [4,6,11,12,14]. Another cause of marginal ulceration is local ischemia. However, a definite consensus has not yet been reached regarding this, because some clinical studies have shown that it is related to the use of nonsteroidal anti-inflammatory drugs [5,14] and others have reported that the phenomena is secondary to the decrease in endogenous prostaglandin synthesis that is usually the protector of the gastric mucosa [15]. As a result, some investigators have switched to absorbable sutures, which has reduced the rate of both marginal ulceration and suture rejection and the risk of hemorrhage [5,11,16,17]. Marginal ulceration should always be treated because of the risk of hemorrhage [18]. Bleeding has been
621
reported secondary to marginal ulceration [17] and can occur several years after RYGB [19,20]. In our experience, we did not find any marginal ulceration or severe bleeding. This was probably because we performed early endoscopy as soon as the patients presented with symptoms of epigastric pain. All these patients were instructed to take a PPI before the endoscopic procedure for 3– 4 weeks, and they had complete relief of their pain even after the PPI was stopped. None of our patients had positive Helicobacter pylori findings, which has also been shown to be one of the causes, together with tobacco use, of marginal ulceration [11,17]. It will be advisable to study patients with and without PPI use, but, at present, not using a PPI is not the standard of care and would place the patient in danger. Our simple retrievable technique we have described provides a solution for those patients who experience problems after the use of nonabsorbable sutures. The 6-month follow-up examination was performed to check on the presence of other sutures, but it is not needed in asymptomatic patients. Endoscopy is required whenever a patient presents with questionable bleeding or epigastric pain, because it is needed to exclude stenosis and other complications of the initial surgery [19,21]. Fig. 4 illustrates our approach to this problem. Whenever patients present with epigastric pain or “heartburn,” we perform upper endoscopy to evaluate the stomach, esophagus, and intestine, with attention directed to the anastomotic line. Although an array of findings may be present at examination unrelated to the original operation, in general, one will find marginal ulceration, a stitch within a marginal ulcer, or stenosis. For marginal ulceration without a stitch present, we recommend a trial of medication. If this fails, reoperation or repeat EGDS with injection of epinephrine or another solution to control bleeding should be performed. For ulcers with the presence of a stitch, we suggested the algorithm we have outlined (Fig. 4). For stenosis, balloon dilation should be performed.
Fig. 4. Stepwise approach in patients complaining of epigastric pain after RYGB (GBP).
622
E. E. Frezza et al. / Surgery for Obesity and Related Diseases 3 (2007) 619 – 622
Conclusion Stitch removal can be easily performed endoscopically using the technique we have described. It should be a part of the armamentarium of surgeons who must evaluate patients who undergo EGDS after presenting with epigastric pain, bleeding, or difficulty eating after LRYGB.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
References [1] Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47–55. [2] Frezza EE, Wachtel MS. Laparoscopic re-exploration in mechanical bowel obstruction after laparoscopic gastric bypass for morbid obesity. Miner Chir 2006;61:193–7. [3] Sapala JA, Wood MH, Sapala MA, Flake TM Jr. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 1998;8:505–16. [4] Marano BJ Jr. Endoscopy after Roux-en-Y gastric bypass: a community hospital experience. Obes Surg 2005;15:342–5. [5] Sacks BC, Mattar SG, Qureshi FG, et al. Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Rouxen-Y gastric bypass. Surg Obes Relat Dis 2006;2:11–16. [6] Dallal RM, Bailey LA. Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis 2006;2:455–9. [7] Szomstein S, Kaidar-Person O, Naberezny K, Cruz-Correa M, Rosenthal R. Correlation of radiographic and endoscopic evaluation of gastrojejunal anastomosis after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:617–21.
[8] Wilson JA, Romagnuolo J, Byrne TK, Morgan K, Wilson FA. Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol 2006;101:2194 –9. [9] St. Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:668. [10] Gumbs AA. Incidence and management of marginal ulceration after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006; 2:460 –3. [11] MacLean LD. Stomal ulcer after gastric bypass. J Am Coll Surg 1997;185:1–7. [12] Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, Wolfe, L. Stomal complications of gastric bypass: incidence and outcome of therapy. Am J Gastroenterol 1992;87:1165–9. [13] Frezza EE, Wachtel MS. A simple venous thromboembolism prophylaxis protocol for patients undergoing bariatric surgery. Obesity 2006; 14:1961–5. [14] Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–29. [15] Kurata JH, Nogawa AN. Meta-analysis of risk factors for peptic ulcer: nonsteroidal anti-inflammatory drugs. Helicobacter pylori, and smoking. J Clin Gastroenterol 1997;24:2–17. [16] Cryer B. Mucosal defense and repair: role of prostaglandins is the stomach and duodenum. Surg Clin North Am 2001;30:877–94. [17] Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 1999;9: 22–7. [18] Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications. Lancet 2002;359:114 –7. [19] Braley SC, Nguyen NT, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2003;13:62–5. [20] Carrodeguas L, Szomstein S, Soto F, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 2005;1:467–74. [21] Huang CS, Forse RA, Jacobson BC, Farraye FA. Endoscopic findings and their clinical correlations in patients with symptoms after gastric bypass surgery. Gastrointest Endosc 2003;58:859 – 66.