a-00025
Dr. Robert RUTLEDGETitle of Paper: BILE, REFLUX, GASTRITIS AND MARGINAL
ULCER FOLLOWING BILLROTH II; MANAGEMENT OF DYSPEPSIA AFTER MINI-GASTRIC BYPASS
Nationality: United States of AmericaPosition: Director
Department: SurgeryOrganization: Center For Laparoscopic Obesity Surgery
Tel: +1-702 714 0011
Marginal Ulcer & Gastric Bypass
Marginal ulcer in jejunum after RNY. 3-cm ulcer (Long arrows) in proximal jejunum abutting G-J anastomosis (Small arrow).
Narrow anastomosis, edema and spasm.
BILE, REFLUX, GASTRITIS AND MARGINAL ULCER FOLLOWING BILLROTH II; MANAGEMENT OF
DYSPEPSIA AFTER MINI-GASTRIC BYPASS
Robert RUTLEDGE11Director, Surgery, Center For Laparoscopic Obesity Surgery, United States of America
Epidemiology: What do we know about Marginal Ulcers?
• “Marginal ulcers represent one of the most problematic postoperative complications following Roux-en-Y”
• Reported “incidence of marginal ulcers is 0.6 to 16 %” in RNY Bypass
As Old as Abdominal Gastric Surgery
• MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER SUBSEQUENT TO GASTROENTEROSTOMY.
• Erdmann JF.
• Ann Surg. 1921 Apr;73(4):434-40
Marginal Ulcer in RNY Gastric Bypass
• 2,282 RNY Gastric Bypass• 122 (5%) Marginal ulcers • 39 (32%) Surgery
• Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08536
Introduction
• Dyspepsia post Mini-Gastric Bypass (MGB, Billroth II gastro-jejunostomy) may be
• Erroneously labeled as "bile reflux." • Thousands of Billroth II (BII) patients have
bile that flows harmlessly across their BII anastomosis every day.
• In 6253 MGB patients, bile routinely flows across their BII with No symptoms.
Introduction
• All patients with a Gastro-jejunostomy (GJ) have a well described risk of a variety of GI symptoms (i.e.: burning, nausea, vomiting, etc.)
• For over 100 yrs General Surgeons have known that all forms of G-J anastomoses can develop Marginal Ulcer
Marginal Ulcer has been known since the beginning GI Surgery
THE ROENTGEN DIAGNOSIS AND LOCALIZATION OF MARGINAL PEPTIC ULCER.
Carman RD.
Cal State J Med. 1920 Nov;18(11):377-82
Marginal Ulcer has been known since the beginning GI Surgery
Re-evaluation of the role of the pyloric antrum in marginal peptic ulcers.
SCHILLING JA, PEARSE HE.
Surg Gynecol Obstet. 1948 Aug;87(2):225-34
Marginal Ulcer has been known since the beginning GI Surgery
Vagotomy as a treatment for marginal ulcer.
CRILE G Jr, BROWN GM Jr.
Gastroenterology. 1951 Jan;17(1):14-9
Marginal Ulcer has been known since the beginning GI Surgery
Review Article: The present status of the management of marginal ulcer.
BYRD BF Jr.
J Tn State Med Assoc. 1953 Feb;46(2):56-8.
Marginal Ulcer has been known since the beginning GI Surgery
2,282 RYGB
122 (5%) Marginal ulcers
39 (32%) Surgery Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal
ulcer after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08536
Marginal Ulcer Very High After RNY Gastric Bypass
441 RYGB
10 (12%) of RNY gastric bypass presented an "early" marginal ulcer
Asymptomatic (28%) Obes Surg. 2009 Feb;19(2):135 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. Csendes A et al Department of Surgery, University Hospital, University of Chile, Santiago, Chile.
Dyspepsia after MGB
• While it is possible that these patients can develop "bile reflux, "
• The usual etiology of dyspepsia following BII
• IS NOT BILE • but the more common of acid peptic
disease (gastritis/ulcer.)
Think Three Pieces of Evidence
• Marginal Ulcer in 100 years of G-J (BII and RNY)
• Marginal Ulcer in RNY Gastric Bypass (No Bile)
• Marginal Ulcer in MGB (+Bile)
Marginal Ulcer Rates
• Marginal Ulcer in 100 years of G-J (BII and RNY)
• (5%)• Marginal Ulcer in RNY Gastric Bypass
(No Bile)• (5%)• Marginal Ulcer in MGB
(+Bile)• (5%)
Results
• Management Protocol: MGB patients suffering from dyspepsia symptoms, (symptoms that might easily be called "bile reflux")
Results
• History: ?Daily Yogurt (protective); Alcohol/processed meats/"junk foods, " NSAIDS, Smoking (“Ulcerogenic”), Labs: H. Pylori, Hgb Fe LFT, s etc.
• Recommend: Yogurt (plain) daily + probiotics, AVOID: alcohol, cigarettes, tobacco, NSAIDs
Results
• Medical treatment: • Rx H. Pylori, • PPI's/H2 Blockers, • +/- Carafate/Bismuth, other antacid
treatment• Note: Never anti-Bile Rx
Results
• In 6253 patients, • Followed for 15 years, • Dyspepsia (5%) • Medical treatment was effective in all
but • 3 patients
(Rx Braun Side to side Jejuno-jejunostomy (J-J).
Conclusions
• The rising adoption of the MGB may lead to confusion when surgeons are faced with post operative BII patients.
• Dyspepsia is relatively common after gastro-jejunostomy (BII = RNY).
Conclusions
• In the vast majority of these cases the etiology is common acid peptic disease causing marginal gastritis/ulcer and is routinely responsive to medical treatment.
• Failure of medical treatment is rare, but easily managed by brief laparoscopic Braun side to side J-J.
Confusion
• Bile• Bile Reflux• Bile reflux Gastritis• Marginal Ulcer
Confusion
• Bile; Everyone has Bile• Bile Reflux; BII has More Bile Reflux than
others• Bile reflux Gastritis; Endoscopy of
symptomatic Pts shows some gastritis in some patients (as in RNY pts)
• Marginal Ulcer; Equal in RNY & MGB• Bile Makes No Difference