Anastomotic Gastrojejunal Ulcer Perforation Following One Anastomosis Gastric Bypass
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LETTER TO THE EDITOR
Anastomotic Gastrojejunal Ulcer Perforation Following One Anastomosis Gastric Bypass Abdulzahra Hussain 1
&
Shamsi EL-Hasani 2
Received: 16 June 2020 / Revised: 24 June 2020 / Accepted: 11 September 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
We read with great interest the article by Abou Hussein [1] regarding the perforation of marginal ulcer at the gastrojejunal anastomosis following one anastomosis gastric bypass (OAGB), which is a rare but recognized complication of this operation. We agree with the contents of the article and the management of these three cases; however, from our experience, we would like to add two points to augment the scientific value of the article. Both RYGB and OAGB are associated with stomal ulcerations that could complicate and result into perforation [2, 3]. Anterior perforation of these stomal ulcers can always be treated by repair with an omental patch with the same principle of the Graham patch. However, for posterior perforation at the gastrojejunal anastomosis, the treatment is different from the excision of the anastomosis and an RYGB construction is the treatment of choice. The excision of the anastomosis will shorten the gastric pouch. OAGB reconstruction is to be avoided as the reflux incidence is expected to be high with a short pouch [4], although a study showed no significant difference between OAGB and RYGB [5]. We think several confounding factors are contributing to the bile reflux and its aftermath of stomal ulcers. These are the length of the gastric pouch, the gastrojejunostomy size and method of creation and the orientation of the anastomosis. The second point is that gastrojejunal stomal ulcer and gastritis may be caused by alkaline bile reflux; therefore,
shifting the bile completely using RYGB construction is suggested [6, 7]. In case the perforated ulcer is treated by omental patch and primary repair, we will strongly recommend side to side (Braun) anastomosis between the efferent and afferent loops (jejunojejunostomy). This will divert the bile from the anastomosis, which logically and/or theoretically will avoid injurious alkaline effect and therefore aid the healing at the site of the perforated ulcer. As the aetiology of these ulcers is not entirely known, such diversion of biliopancreatic secretions may be the radical cure for this particular type of stomal ulcer as it is one of the theories that the bile acids are the cause of these ulcers, at least in some of the cases. We have reported four cases, of which two anterior perforations were treated with omental patch and Braun anastomosis and two posterior perforations were treated with anastomosis resection and RYGB construction. One patient developed recurrence of an ulcer and one patient developed bleeding, both managed conservatively, and the mean follow-up of 3 years(6 months-5 years) did not show further complication of these revisions.
Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of inte
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