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Checklists in Bariatric Surgery Bariatric Times • January 2014 P Checklists in Bariatric Surgery Column Editor RAUL J. ROSENTHAL, MD, FACS, FASMBS CHECKLIST #16 Gastro-jejunal Anastomotic Ulcers After Roux-en-Y Gastric Bypass Clinical Editor, Bariatric Times, Professor of Surgery and Chairman, Department of General Surgery; Director, The Bariatric and Metabolic Institute; Director, General Surgery Residency Program and Fellowship in Minimally Invasive and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida Column Co-editors SAMUEL SZOMSTEIN, MD, FACS, FASMBS Associate Director of the Bariatric Institute and Section of Minimally Invasive Surgery at the Cleveland Clinic in Weston, Florida, and Clinical Associate Professor of Surgery, Florida International University E. LO MENZO MD, PhD, FACS, FASMBS Staff Surgeon, The Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic Florida, Weston, Florida. W elcome to "Checklists in Bariatric Surgery." This column's aim is to help bariatric surgeons quickly review the reasons for potential problems when caring for bariatric patients. This month's Checklist focuses on gastro-jejunal anastomotic ulcers after Roux-en-Y gastric bypass. The incidence of marginal ulceration at the gastro-jejunostomy has been reported between 1 and 16 percent. Concomitant anastomotic strictures have been described in up to 27 percent of the cases. We present this 16th installment of "Checklists" based on peerreviewed publications, which might help our readers communicate better and treat patients expeditiously. We hope you clip and save this convenient checklist and find it useful as a reference tool in your everyday practice. Please stay tuned for more checklists in upcoming issues of Bariatric Times. REFERENCES 1. Court I, Zissman P, Rosenthal RJ. Diagnosis and treatment of Zollinger Ellison syndrome in a morbidly obese patient after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6(6):714–717. 2. Patel S, Szomstein S, Rosenthal RJ. Reasons and outcomes of reoperative bariatric surgery for failed and complicated procedures (excluding adjustable gastric banding). Obes Surg. 2011;21(8):1209–1219. 3. Carrodeguas L, Szomstein S, Zundel N, Lo Menzo E, Rosenthal R. Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery analysis of 1291 patients. Surg Obes Relat Dis. 2006;2(2):92–97. FUNDING: No funding was provided. DISCLOSURES: Dr. Rosenthal receives educational grants from Covidien, Baxter, Karl Storz, W.L. Gore, and Ethicon EndoSurgery. He is on the advisory board of MST. Drs. Szomstein and Lo Menzo report no conflicts of interest relevant to the content of this article. 13 Bariatric Times. 2014;11(1):13. READER HANDOUT: Cut, copy, and distribute. P CHECKLISTS IN BARIATRIC SURGERY CHECKLIST #16 Gastro-jejunal Anastomotic Ulcers After Roux-en-Y Gastric Bypass by RAUL J. ROSENTHAL, MD, FACS, FASMBS; SAMUEL SZOMSTEIN, MD, FACS, FASMBS; and EMANUELE LO MENZO, MD, PhD, FACS, FASMBS Bariatric Times. 2014;11(1):13. The incidence of marginal ulceration at the gastro-jejunostomy has been reported between 1 and 16 percent. Concomitant anastomotic strictures have been described in up to 27 percent of the cases. P History __Recurrent epigastric, substernal pain ± radiation to the back, usually associated with food intake __Nausea and vomiting with intolerance to solids and/or liquids (suspect associated stricture) __Anemia, heme + stools, or hematemesis/ hematochezia __Previous marginal ulcers P Diagnosis __EGD • Also look for associated: __Foreign bodies: Stiches, staples, eroded anastomotic rings. Remove if safe. __Stenosis: Dilate until able to advance the endoscope across the anastomosis. Might need more than one session to achieve this result. Repeat EGD for more aggressive dilatation in 4–6 weeks after ulcer healed. __If pre-anastomotic ring, do not dilate and consider ring removal. __Gastro-gastric fistulae. __Active bleeding: inject with saline or epinephrine and use additional modality (coagulation or clips) P Treatment P ACTIVE BLEEDING __If massive: admit to ICU/OR, intubate to secure airway, perform endoscopy and use CO2 in case patient needs to undergo laparoscopic treatment to avoid small bowel distension. __If mild to moderate: Endoscopic control in Endosuite/ICU depending on patients hemodynamic status. __After endoscopic control/surgery start proton pump inhibitor (PPI) drip. Change later to twice a day __Check H/H q 4–6 hours __Discharge patient on PPI BID for 6-8 weeks and Sucralfate suspension 4–6 times a day. Modification of risk factors (Tobacco, smoking). Repeat EGD in 6–8 weeks. __If unsuccessful or recurrence: surgical over sewing of bleeding ulcer bed. P Review risk factors: __Smoking, medications (NSAID's, steroids, etc.) __Hx of H.pylori infection (controversial association) __If recurrent episodes,also ask for weight regain (Gastrogastric fistula) __Get operative report, if possible. Look for non-divided RYGBP, preanastomotic rings/bands. __UGI: Sometimes useful to demonstrate stricture or G-G fistula (use G-G fistula protocol with oblique and left lateral decubitus pictures) • __If done prior to EGD: Use gastrografin so no delay in performing the EGD is caused due to Barium. __If recurrent or refractory marginal ulcer, especially in the absence of risk factors, rule out the presence of hypersecretory states, such as gastrinoma (check gastrin levels). Consider 24-pH __If gastrinoma diagnosed: __Octreotide scan. Gastrin levels. Can do EUS only in the OR via transremnant enoscopy. __CT SCAN: if G-G fistula suspected (gastric remnant distention with air and contrast). • __If done prior to EGD: Use gastrografin so no delay in performing the EGD is caused due to Barium. P NO BLEEDING: __PPI daily or twice daily, Sucralfate suspension 4-6 times a day. smoking and NSAIDs cessation. __Re-evaluate in 6 weeks. • If symptoms resolved: __First episode- discontinue treatment. __Recurrent episodes- continue PPI indefinitely • If no improvement: __Repeat EGD • Improvement continue treatment • No improvement work up for hypersecretory states (see above) P STENOSIS __Endoscopic dilatation (either using through-the-scope balloon dilators, or Bougie dilators). __If recurrent, some suggest endoscopic steroid injection __Refractory cases will require re-do gastro-jejunostomy P PERFORATIONS: __Washout and drains. __Graham patch alone, or primary closure with omental patch P GASTRO-GASTRIC FISTULA __Refer to Checklist #8: Gastro-gastric Fistula after Roux-en-Y Gastric Bypass (Bariatric Times. 2013;10(5):13) P REFRACTORY OR CHRONIC ULCER __Surgical excision of ulcerated anastomosis and re-do gastrojejunostomy (± truncal vagotomy) or pouch excision and esophagojejunostomy. Please refer to full column installment for full list of references. Disclaimer: The information in this handout is for educational purposes only and should not be used as a primary source of treatment. Sponsored by Matrix Medical Communications Publishers of Please visit www.bariatrictimes.com to download the PDF of this handout OR scan the QR code to the right for a direct link to the Bariatric Times website.