Laparoscopic Conversion of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass Due to Penetrated Marginal Ulcer
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MULTIMEDIA ARTICLE
Laparoscopic Conversion of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass Due to Penetrated Marginal Ulcer Ron Dar 1,2 & Tamar Dola 1 & Dan Hershko 1,2 & Hadar Aboody Nevo 1,2 & Nasser Sakran 1,2 Published online: 16 April 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Keywords Morbid obesity . Gastric bypass Roux-en-Y . One anastomosis gastric bypass . Marginal ulcer
Introduction Laparoscopic one anastomosis gastric bypass (OAGB) is gaining ground as a safe and effective operation for morbid obesity [1, 2]. Less than 5% of the patients may require revision surgery, with half of the revisional surgeries due to severe malnutrition and the other half due to bile reflux, ulcer, and/or weight regain (https://www.ifso.com/one-anastomosisgastric-bypass). Nonetheless, OAGB may lead to some difficult to treat complications such as a marginal ulcer (MU). The incidence of MU after OAGB is reported to be around 5.6% [3, 4]. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-020-04602-4) contains supplementary material, which is available to authorized users. * Nasser Sakran [email protected] Ron Dar [email protected] Tamar Dola [email protected] Dan Hershko [email protected] Hadar Aboody Nevo [email protected] 1
Department of Surgery A, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111 Afula, Israel
2
Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
Risk factors for MU include poor tissue perfusion due to tension or ischemia at the anastomosis; the presence of foreign material, such as staples or nonabsorbable suture; excess acid exposure in the gastric pouch due to gastrogastric fistulas; nonsteroidal anti-inflammatory drug use; Helicobacter pylori infection; and smoking [5]. Treatment with a high dose of proton pump inhibitors (PPI) and elimination of risk factors is started first [6], but when conservative treatment fails with an unresolved ulcer, a surgical approach should be considered including conversion to Roux-en-Y gastric bypass (RYGB) [7].
Methods We present a case of an obese 44-year-old male heavy smoker with obesity-related comorbidities who underwent OAGB on July 2016. Two years post-surgery, the patient suffered from epigastric pain and was diagnosed with a deep MU. Despite long treatment with high doses of PPI along with sucralfate, the ulcer had not resolved and a surgical treatment was considered due to lack of response to medical treatment. We have discussed with the patient about the importance of smoking cessation and the high risk associated with the development of additional margin ulcer following bypass surgery should he resume smoking. We have also addressed the need for longterm treatment with PPIs. Given the fact that during gastroscopy, there was a single ulcer with no evidence of gastritis or esophagitis, and other potential causes for ulcers were considered such as technical factors or ischemia, we concluded that RYGB was a good opt
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