Marginal Ulcers Following Roux-en-Y Gastric Bypass, Expect the Unexpected: a Video Case Series

Background Marginal ulcers (MUs) have been a source of significant morbidity among patients who have undergone Roux-en-Y gastric bypass (RYGB) surgery. In addition to variable anatomic locations, MUs have a wide range of clinical presentations. Management of such complex cases requires not only familiarity with the challenging anatomic variances but also the technical ability to effect resolution. Five distinct cases of MUs are presented to demonstrate this challenging complication of RYGB in order to assist the bariatric surgeon in surgical decision-making.Methods Data from chart review and intraoperative recordings were compiled to create a video case series. Five cases were selected with variable presentations of marginal ulcers that all required distinct procedural interventions for management. The cases were performed between 2017 and 2022 at a high-volume bariatric center by a single surgeon.Results Five cases were included. Each case had a distinct affected location and level of complexity requiring different operative approaches. Case 1 involved the management of recurrent nonhealing MUs with laparoscopic revision of the gastrojejunal anastomosis, pouch optimization, and truncal vagotomy. Case 2 addressed obstructive symptoms caused by a severe anastomotic stricture from chronic marginal ulceration with an endoscopic guided gastrojejunostomy. Finally, cases 3-5 were acute in nature with patients presenting with peritonitis secondary to MU perforation. Cases 3 and 4 underwent a diagnostic laparoscopy with a Graham patch or modified Graham patch repair of the perforation. Case 5 was managed with laparoscopic reversal of the RYGB. Cases 1, 3, and 4 had resolution of their MUs. Case 2 was reversed 3 months following the initial intervention. Case 5 reversed at the time of their acute presentation.Conclusion MUs have a wide range of complex clinical presentations. Management of such cases requires familiarity with the anatomic variances of MUs as well as the operative skill to effect resolution

Automated summary

This article presents cases of marginal ulcers (MUs) in patients who have undergone Roux-en-Y gastric bypass (RYGB) surgery and discusses the different treatment strategies. MUs have a wide range of complex clinical presentations, and managing them requires familiarity with their anatomic variances and operative skill to effect resolution.