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