Incidence of Marginal Ulcers After Gastric Bypass Seems to Be Inversely Related to the Duration of Prophylaxis with Prot
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LETTER TO THE EDITOR
Incidence of Marginal Ulcers After Gastric Bypass Seems to Be Inversely Related to the Duration of Prophylaxis with Proton Pump Inhibitors Kamal K. Mahawar 1 Received: 12 September 2020 / Revised: 12 September 2020 / Accepted: 13 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Dear Editor, I read the article by Baksi and colleagues [1] published recently in “Obesity Surgery” with keen interest. In this study, authors found asymptomatic marginal ulcers (MU) in 4/42 (10.5%) patients a year after one anastomosis gastric bypass (OAGB). Marginal ulcers are a major cause of morbidity after both Roux-en-Y gastric bypass (RYGB) [2] and OAGB. Approximately 17% of patients need surgical intervention after a diagnosis of MU over the ensuing 8 years for complications such as bleeding, perforation, stricture, and gastrogastric fistula [2]. Some of these can be life-threatening [3]. It would, therefore, be worth examining if it is possible to reduce their incidence. Kang et al. [4] have previously observed that increasing the duration of PPI prophylaxis from 30 to 90 days reduced the symptomatic ulcer rate to 6.5% from 12.4%. Baksi and colleagues [1] have increased the duration of proton pump inhibitor (PPI) prophylaxis in their cohort to 12 months from 6 months based on their findings. This approach would be supported by a systematic review on this topic [5] where authors observed a “significant incremental benefit of prophylactic PPI in reducing marginal ulcer after gastric bypass surgery.” It would, therefore, be useful to know if even longer durations of PPI prophylaxis more than 12 months would be associated with further reductions in the MU rates. There seems to be some anxiety [6] in the minds of physicians regarding the adverse effects of long-term use of PPI. It is worth noting here that the American Gastroenterological Association recommends the use of long-term PPI in a variety of clinical situations [7]. Authors [7] did not even recommend
* Kamal K. Mahawar [email protected] 1
Bariatric Unit, Sunderland Royal Hospital, Sunderland SR4 7TP, UK
concurrent supplementation with calcium or vitamin B12 for these patients. One expects concerns with regard to the absorption of these micronutrients to be even lower in gastric bypass patients who are routinely supplemented with these micronutrients and regularly monitored [8]. There is considerable variation in practices with regard to the drug, dosage, and duration of PPI prophylaxis after OAGB. The duration ranged from 2 weeks to lifelong in one study [9]. Given that most MUs present within the first 5 years after a gastric bypass [2, 10] and that the risk of MU seems to decrease with time [10], I recommend PPI prophylaxis to my gastric bypass (both RYGB and OAGB) patients with lansoprazole 30 mg daily for 5 years. I, therefore, wholeheartedly support the authors’ plans [1] to increase the duration of PPI prophylaxis for their patients from their current practice of 6 months to 12 months. In fact, I might sug
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