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Clinical Challenges in Bariatric Surgery: Marginal Ulcers · Behind The Knife: The Surgery Podcast

• BTK Marginal Ulcers === [00:00:00] Welcome back to Behind the Knife, the Bariatric Surgery Specialty Series. I am Katie Sironi, a general surgery resident at the University of Southern California, and I am joined today by our expert panel of bariatric surgeons. Dr. Martin I'm Matt Martin. I'm a trauma and bariatric surgeon at University of Southern California. I'm here with my, co-partners. I'll turn it over to Crystal I am Crystal Johnson Mann. I'm a bariatric and foregut surgeon at the University of Florida, where I am also our medical director of bariatrics. And Adrian Hi, I'm Adrian Dan, and I'm, Medical Director of Bariatrics and Fellowship Director for the Advanced GI MIS Bariatric and Foregut Fellowship at a place called Summa Health System, Northeast Ohio Medical University in Akron, Ohio And today, we're tackling a complication that every bariatric surgeon dreads, marginal ulcers. It's one of the most common complications after Roux-en-Y gastric bypass, with the reported prevalence ranging widely from zero point six percent to sixteen percent, [00:01:00] depending on the series, and about a pooled mean prevalence of around four point six percent. these can range from a simple annoyance to a life-threatening emergency And that's the key challenge with marginal ulcers. They're unpredictable. We can identify risk factors, we know how to treat them medically, but we're still learning how to prevent them and when to escalate it to surgery. This episode, Katie, is really about giving you a framework about managing these patients across the entire spectrum of the severity of this condition And so we're gonna approach this today by working through, three clinical scenarios that really represent the spectrum of marginal ulcer disease from the least complicated to more complex presentations. and each one of these cases is gonna help us discuss the etiologies, risk factors, and stratification, and decision-making for the surgeon that's called upon to manage these. before we actually take a deep dive into these cases, let's sort of ground ourselves in what we actually [00:02:00] know about why marginal ulcers develop The pathophysiology is multifactorial, thought to be due to smoking, H. pylori, diabetes, and larger pouch size. Pouch length has been independently associated with ulcer formation, which points to both increased acid exposure and mucosal ischemia as contributing factors Yeah, and it's important to note, that there are some factors initially thought of as influential that might not be as significant. In one meta-analysis out of the Mayo Clinic that looked at fourteen studies in over three hundred and forty thousand patients, they noted certain factors that were not predictive of marginal ulcer development. And these included things like age, body mass index, gender, obstructive sleep apnea, hypertension, and even alcohol use Yeah, that's a lot of patients, Matt, but interestingly about that meta-analysis is that NSAIDs were noted as a possible risk factor but did not reach statistical significance. You know, that [00:03:00] doesn't mean tell your patients to go take NSAIDs or ibuprofen, but it does mean that the evidence base is somewhat more mixed than the known dogma And but there's still some debate in the literature. So in yet another meta-analysis that came out in two thousand twenty-five and had over two hundred and fifty thousand patients included, found that there was no significant association between preoperative H. pylori and marginal ulcer formation after a Roux-en-Y gastric bypass. But that comes with a real caveat. between these studies was enormous pool of confidence interval ran from zero point two three to five point eight eight. So that's not evidence that H. pylori doesn't matter, but more so that our current studies disagree so much that we really can't tell What I found most important in my practice, however, is that these aren't random events. We can screen for H. pylori preoperatively, and we can eradicate if it's positive. We can counsel patients about smoking cessation. We can [00:04:00] prescribe PPIs postoperatively. We can discuss other ulcerogenic factors, and we're making decisions like pouch size that could possibly modify risk factors. You make a smaller pouch, you've got less, cell mass to secrete acid. So while we can't eliminate marginal ulcers, we should be more aggressive about preventing them, and I'm gonna say we should maybe be doing more SADI and less bypass. That may be one way to prevent them, but that's, uh, that's for another day we will note that the incidence of marginal ulcer with SADI and duodenal switch is not zero. ครับ Roux-en-Y gastric bypass, but you can still see them after any of the anastomotic options Without a doubt Very good point. right, let's dive into our first patient. This is a thirty-five-year-old man with a BMI of forty-two who presents four months after a laparoscopic Roux-en-Y bypass with new onset postprandial epigastric pain. His pain started about a month ago as mild discomfort [00:05:00] and has progressively worsened. He denies vomiting and hematemesis but has notic-noticed decreased appetite since eating triggers his pain. An upper endoscopy shows a one centimeter shallow ulcer at the GJ anastomosis with surrounding erythema, but no active bleeding and no perforation. His hemoglobin is stable. Dr. Martin, what would you do next? So first, I'd classify this as kind of the simplest or less complicated presentation. I'd certainly complete his etiologic workup and try to figure out what's causing this ulcer. is he on NSAIDs? Uh, How much and how often is he taking them? Is he on any immunosuppressant medications? Does he have a history of peptic ulcer disease or H. pylori? And if not, has he been screened for H. pylori? Very important, is he currently smoking? and, since the endoscopy was done, uh, did they see any visible foreign material at the anastomosis like suture? In some studies, sutures were visible in up to thirty-five percent of patients with marginal ulcers. in fact, the twenty [00:06:00] twenty-five, ASMBS algorithm for marginal ulcers includes removable, endoscopic removal of visible staples or non-absorbable suture material as part of the first-line treatment So let's just say that he denies NSAID use. He quit smoking preoperatively, and his prior H. pylori testing was negative. So overall, we're looking at a relatively low risk profile and an uncom-complicated presentation. case, medic, management is kind of really the initial sort of treatment, with proton pump inhibitor therapy with or without super And, Crystal, here's a pearl that a lot of people often miss. Uh, Some work that's been done by Chris Thompson and even our good friend, uh, Shanu Kothari at ASMBS has, talked and researched this. But PPIs as capsules, and after a bypass, you have a tiny little pouch and very fast bowel, transit time, which limits the capsule breakdown and absorption time. Having the patient open the capsules in, let's say, some [00:07:00] yogurt or another food, has been shown to have a significantly faster healing time for the ulcer, and that's a nice thing for your patients to know Now that's a simple intervention, Dr. Dan. We should definitely tell all of our patients to open the capsule. Now what about adding sucralfate, Dr. Martin? Do you typically do that? I'll say that the practice varies pretty wildly, Katie. evidence is relatively equivocal. There have been several studies that looked at healing rates and showed , healing rates with PPI alone PPI plus sucralfate, , were essentially equivalent. , Although there is a high healing rate with both of those. , I tend to add it, especially if the patient's having significant pain component with PO intake. , But I don't necessarily know that it, , increases the healing rate And I counsel patients that even though we are treating medically, it takes a while for things to heal. I would typically schedule a repeat endoscopy in a month or two to document the healing. There's some published [00:08:00] success rates with medical treatment of uncomplicated marginal ulcers, and in the literature, it ranges from about 67 to 100% in some series at the time of first follow-up endoscopy. However, there's still about a 10% risk that the medically managed marginal ulcers will at some point require a surgical intervention Good point, Dr. Dan. So in this patient, assuming the repeat endoscopy shows that the ulcer is healing, what's your long-term strategy for medical management, Dr. Johnson-Mann? really, Katie? There's no consensus on duration. the strategies in in the literature include continuing until endoscopically confirmed, you know, healing, which is anywhere from a fixed course of three to twenty-four months, or sometimes even lifetime therapy if needed. but with anything in medicine, and in our specialty is no exception to this, practice patterns do vary greatly. know, for some patients, you may want to, consider lifetime prophylaxis in patients that have had recurrent ulcers, continued smoking, or, anatomic abnormalities, [00:09:00] or, you know, for patients who need to be on lifetime NSAIDs, aspirin, maybe they have coronary artery disease, maybe they have vasculitis, et cetera. Yeah, and for all patients, I really reinforce all of the risk factor modifications, no NSAIDs, unless they're absolutely necessary, continued smoking cessation, regular clinic follow-up to follow their symptoms and to make sure they don't get lost, and if you need a, a repeat endoscopy, that that gets done. and the definition of refractory really matters for setting expectations. ulcer that hasn't healed after treating those underlying causes and a continuous PPI for 12 months can safely be called refractory, uh, I would personally use six months or greater, of optimal therapy to define refractory if there hasn't been healing. I was gonna chime in, Matt, and say that 12 months is a long time to live with an ulcer, and while that may be common in the literature, I think most bariatric surgeons tend to act a little bit faster, even three to six months Got it. [00:10:00] Now, Dr. Dan, what about imaging? Is it warranted to order a CT scan at presentation for a patient like You know, Katie, in this uncomplicated case, with stable vital signs, with no evidence of peritoneal signs, I would say no. Endoscopy is going to be your best diagnostic tool. You may couple that with an upper GI contrast study, but really a good endoscopy should be enough. CT scanning earns its place when, you're concerned about perforation, you're looking for free air, free fluid, inflammation in the acute setting, emergency evaluations, et cetera. You're looking at that gastrojejunostomy and, trying to make sure there's no contrast extravasation. But a straightforward marginal ulcer disease, imaging just adds cost, but really doesn't add much to the management Although, to be fair, sometimes people are presented to the ED with abdominal pain and a history of gastric bypass, and they end up with a CT. And I think that's what I more commonly see there for something else, and then you'll get a CT scan. You'll see some stranding around the GJ, but nothing else kind of [00:11:00] going on. It kind of just confirms they need to have outpatient follow-up and so on, so forth Got it. Thank you. for our second case, this is a forty-eight-year-old woman. She is eighteen months out from her bypass. She was diagnosed with a symptomatic marginal ulcer at six months post-op. She was started on PPI therapy and initially improved, but her pain reoccurred around twelve months post-op, and repeat a stricture at the ulcer site with significant narrowing of the anastomosis. She's been through four endoscopic dilations over the past six months with temporary improvement, but symptoms keep returning. Now she can only tolerate liquids Yeah. And so, so I think now we've crossed over into what I would call complicated marginal ulcer disease. and these can be incredibly frustrating for both the surgeon and the patient, but also increasingly common. GJ strictures after gastric bypass, have a reported incidence, ranging from three to twenty-seven percent. These [00:12:00] strictures are often the product of a healing marginal ulcer, which is laying down excess scar tissue and inflammation, which can then cause obstruction and food intolerance or tolerance to liquids only for our patients. The incidence also depends on the anastomotic technique that was utilized. The highest rates of strictures have been reported for smaller diameter circular staple anastomoses, although I think those have largely been abandoned now. But in this scenario, the etiology is clearly related to marginal ulcer, versus a technical issue with the anastomosis. And Matt, I'm gonna take advantage of the point that you made to mention that, in the early experiences that we have, it turns out that magnetic anastomoses are highly prone to perforation with based on data that's been reported thus far, more than any other type of, anastomosis. And of course, our biggest fear when dilating, as you mentioned, is, the possibility of a perforation. Luckily, this is rare. I've had it happen twice in my [00:13:00] career. Perforation, rates are noted to occur about 2% of the time of cases when patients are receiving, dilation. And, oftentimes, I think if we were to study these patients with, radiographic studies, we'd see some free air in a lot of patients which do not have a frank perforation just due to the endoscopy and the dilation. But in a patient that has more pain than you would expect and a CT shows a large amount of free air, you may see a, uh, stricture that is actually perforating at the ulcer, which is the main reason for the scarring and, , the subsequent stricture. So something to keep in mind Yeah, absolutely. for this patient with refractory dilations, before we consider surgery, let's first make sure we understand why this is happening. First, is the patient on adequate PPI therapy? And as we've already kind of discussed, is she opening the capsules? Sometimes in recurring cases, we find that patients [00:14:00] were de-escalated when their symptoms improved, so this is a really important point to sort of inquire about. is there a GG fistula, gastro-gastric fistula? Because that's another classic case, of causing refractory ulcer disease. And most importantly, is the patient smoking or having heavy secondhand smoking exposure in addition to taking the actual smoking history, which- You know, I always tell my residents this, you have to ask about vaping. You gotta ask about all nicotine exposure, period. Snuff, dip, all that stuff also includes. And then I would confirm this with a serum nicotine and cotinine test Absolutely. Now let's assume she's on the appropriate medication management and imaging shows no obvious gastric fistula. Now, what's next for the refractory ulcer and strictures? I would say just to complete the workup and rule out the zebras, check a serum gastrin to rule out a hypersecretory state or a gastronoma. So now we have a persistent inflammatory response despite optimal acid suppression. The next step [00:15:00] for me, if we've exhausted the medical and endoscopic therapy, generally be surgical and revision of the anastomosis. So resection of the gastrojejunostomy, including all the involved ulcerated or ischemic tissue, including taking down any associated gastrogastric if it's present. and then I would also downsize the pouch if it's found to be enlarged. But, but by definition, by resecting the anastomosis, you are automatically downsizing the pouch somewhat. Beyond that, options escalate to resection of the bypass stomach, if you think that might be a source driving it, truncal vagotomies, and then getting into more complicated options like resecting the entire pouch, , which then usually leaves you with a esophagojejunostomy as an option. you can always reverse the gastric bypass if the remnant is intact, and the patient's in nutritional trouble, and you think that's a better option Now let's say we choose the revision of the GJ. How durable do you find this, Dr. [00:16:00] Johnson, man? Outcomes are mixed. And the evidence seems as heterogeneous as well. So one study followed thirty-eight patients who underwent GJ revision and found that eighty-seven percent did not develop recurrent ulcers, and of those that did, three were smokers. However, in contrast, another study following twenty-eight patients after revision found that one year only thirty-six percent of patients had symptom resolution that fifty-seven percent of those patients had endoscopically proven recurrence, with three ultimately requiring reversal to gastric bypass And these are major operations. Are there any less invasive options, Dr. Dan? Well, there are, Katie. However, the data is quite sparse. You know, there are some data noting endoscopic options. There's a group from, Johns Hopkins described 11 patients with, refractory marginal ulcers. Of these, seven underwent endoscopic suturing, and two had placement of a fully covered self-expandable endoscopic stent, and actually two of them underwent both.[00:17:00] At eight weeks, 90% of the patients, had complete ulcer healing on,, post, , procedural endoscopic follow-up. So there's some data out there on some novel techniques, but they're not commonly being used. I will also take this opportunity to add to what Matt mentioned about completing the workup for these patients, and, serum nicotine and, urine cotinine levels may be a good addition. You'd be surprised how many people say, "You know, Doc, I don't smoke. Oh yeah, but I vape." Or how many different, types of powders and, , remedies exist out there contain NSAIDs without the patient possibly not even knowing. So it's always important to dig in a little bit deeper and try to identify , the offending agent One point to that, Adrian, I also inquire about marijuana use. Because smoking marijuana can also, oftentimes people will roll those with cigarette paper, obviously is gonna have some exposure to nicotine. So edibles, fine, do it. lighting it up, different story I'm glad you mentioned [00:18:00] that, Crystal, 'cause I know nothing about, about that. But Matt, what do you guys do out in California, Matt? so, uh, I'd say we, we follow trust but verify had patients who say, you know, "I don't smoke," and, and they don't smoke. They live with a heavy smoker, and they're constantly inhaling secondary smoke, but they've told you they're not smoke. Yeah, so I definitely would, would get the cotinine test. addition to the endoscopic option, there is also truncal vagotomy. this is often done thoracoscopically on the distal esophagus, and the theory is you avoid the scar tissue surrounding the pouch and the potentially hostile environment of the post-op upper abdomen. Although I, found that it's not necessarily that difficult to approach that laparoscopically, and have not had major problems identifying the vagus nerve. So do wanna ask your, opinion on, of not laparoscopic but robotic techniques. I think, with the robotic stability, we're relying less and less on our thoracic surgery colleagues [00:19:00] for approach. Would you agree with that? I would agree. I'm a big fan of the robot, especially for visualization, you know, for fine structures and dissection like this. I think it's a, a great, technique and just speaking of that, there's, also a in the literature out of, Oregon Science University. A team there compared 23 patients, of which 13 had a gastrojejunostomy revision and seven had, thoracoscopic truncal vagotomies. Interestingly, also recurrence was similar between the groups, about 15% in each, and more complications were noted, in the revision group as would be expected. They must not have done it robotically Let's, let's bring us back to this patient. So I, I think one could consider an advanced endoscopic suturing technique. One could, right? But before offering surgery, something that I do all the time in my practice, which I like to thank my GI colleagues for this in motility, I would first [00:20:00] confirm if the patient is a genetic rapid or ultra-rapid via the CYP2C19 pathway, because that is the pathway through which the vast majority of PPIs get metabolized. So if they have rapid metabolism or ultra-rapid rapid metabolism, then they're not going to respond to open capsule omeprazole, protonix, dexilant, the whole shebang. Now, Nexium, esomeprazole, is a little questionable if it goes down that pathway, but ordinarily if patients are a rapid or ultra-rapid they usually end up on Aciphex, which is rabeprazole. If they can get insurance coverage for it, that's the catch. But Aciphex comes in tablet form only. It's very hard to get the granule forms. So if I know someone is a rapid metabolizer, I will usually, if I need to like post-operatively, I'll usually have them get Nexium and open capsule that for three months, , and then transition them back to their home rabeprazole or Aciphex. Crystal, how do you determine that? Is that by suspicion, or is there a test so comes to me with refractory GER, whether it's a foregut patient [00:21:00] or someone with recurrent ulcers and is sitting in a gastric bypass anatomy they have been on a multitude of PPIs, and if I think that they've been taking them as directed, then I will usually test them. And the test comes back, one to three weeks depending, but you can order the CYP2C19 by itself. It usually is like a send out lab for LabCorp or Quest. We actually at UF have something called the Gator PGX panel, which gives us a whole bunch of different enzymes, not just that one. so it's very helpful. So then if that person, and I know they're not a rapid been on appropriate PPI therapy and they fail despite maximal medical therapy, then we're talking about revision surgery, in which case I actually would also usually employ a truncal vagotomy, which I also do from the abdomen, with an honest conversation with the patient that recurrence is still a real risk. Now for this patient, we can't forget that she, like many of our patients, may be restricted to a liquid diet for weeks to months. How would you assess her nutritional status, Dr. Martin, and when would you operate? Yeah, and I think that's a critical consideration, right? 'Cause you [00:22:00] may have one shot at revising this before you, you're obligated to something like an esophagostomy. So prior to surgery,, I would just order our standard baseline bariatric labs, some protein markers like albumin and prealbumin, iron studies, B12, folate, calcium, vitamin D. If she's significantly depleted, pre-op optimization with supplemental nutrition is usually worth delaying surgery, until the patient's a little more optimized. there also, are some advocating now for testosterone replacement in these patients as part of their nutritional optimization. but patients like this with complicated ulcers obviously might be at risk for long-term malnutrition, especially if they've also been smoking. might need feeding access, placed into the gastric remnant. so we can consider or tacking the bypass stomach to the abdominal wall for later percutaneous access if they don't need, feeding access up front. Perfect. Now with our third case, [00:23:00] this is a forty-two-year-old woman. She is twelve months out from her bypass. Now she's presenting to the ER with acute onset severe abdominal pain that started this morning. She's tachycardic, febrile, and is guarding with rigidity on exam. An upright chest X-ray shows free air under the diaphragm. confirms free air and free fluid around the GJ anastomosis. are your next steps, Dr. Johnson Mann? clearly this is a surgical emergency, and so it's really worth commenting on just how common this is. So the incidence of a perforating marginal ulcer after a gastric bypass runs from anywhere from about point four four percent to one percent. for those who have a known marginal ulcer, it's about twenty percent of patients will present with perforation. So when we're considering those with refractory marginal ulcers, this is actually not that rare this patient's management, Katie, should start with, resuscitation. We, of course, wanna make sure that the patient is, prepared for surgical intervention. They should receive prompt IV [00:24:00] fluids and broad-spectrum antibiotic administration. And surgical intervention should be early to reduce, the potential for septic complications So, a obviously, if the patient's hemodynamically unstable despite resuscitation, that patient should go straight to the OR. and you can resuscitate just as well in the OR as you can in the ICU, and you need to get source control. You don't even need to wait for the CT scan. If you have free air, in that patient, they can go right to the OR. in an emergency situation, a general surgeon should be able to explore the patient and treat this either laparoscopically or open, and then can transfer to a bariatric center when the patient is stable if a bariatric surgeon wasn't available immediately. however, one thing I do tell my general surgery colleagues is if the patient's not unstable, there's often a, "They've got massive free air. We need to go and do a laparotomy." And I tell them, "You can almost always put a scope in first. It's usually a small anterior perforation and [00:25:00] a couple stitches, is usually all you need to do." So you can do, I would say, the vast of the, of these laparoscopically and avoid a laparotomy let's say we're in the operating room. What are our options, Dr. Johnson-Mann? like what Matt mentioned, right? The default and what most bariatric surgeons would do is diagnostic laparoscopy. We'll wash the patient out really thoroughly. We do a primary repair of the perforation and do an omental patch, which is a modified Graham patch. and then don't forget to leave a drain next to the repair. the washout's important for reducing postoperative internal access I also would do an intraoperative endoscopy, which I've had to do, which has been the only way I could have found the perforation sometimes 'cause it's so small. and this helps with identifying the perforation site, the size, the number, the depth of the ulcers, and then you can also take biopsies, from, you know, externally or tissue biopsies endoscopically Yeah, but there is some debate, in practice and in literature. there there was a study out of Stony Brook that looked at about three hundred patients who presented with perforated marginal ulcer. about thirty-nine percent underwent repair of the [00:26:00] ulcer. twenty-two percent underwent revision of the GJ, which actually was surprising to me. that that seemed like a high number to be doing an acute revision. those that underwent revision were more likely to have respiratory complications, longer hospital stay. That's not surprising. and interestingly, recurrence of the marginal ulcer was common for both interventions, about twenty-six to twenty-nine percent incidence in each group So now the other caveat is that revision during emergency surgery is technically harder. It requires a hemodynamically stable patient and bariatric expertise typically. So the decision is really made intraoperatively, and it's all about the patient in front of you. What you don't want to do is commit to a large resection and revision in a patient with severe inflammatory changes and poor tissue quality because this is really just setting the patient up for complications after surgery, a leak, need for more interventions So Dr. Dan, what happens with the truly catastrophic cases, catastrophic Yes. So I'll tell you, I'll [00:27:00] start by saying that in, in a 20-plus year career, I've never done an acute GJ revision. I'm sure maybe someday I'll have to. But it's really a difficult undertaking, especially since these happen in the middle of the night with, not your regular staff, you may not have the appropriate help, instrumentation, et cetera. So basically in my experience, I've closed just about every marginal ulcer that came my way, and sometimes it's really impressive what, you can close. Some of them were so large that I just wonder if they actually count as a gastrojejunostomy revision. I've had one that was more than 50% of the circumference, and it healed just fine. But that's your best out, is to try to attempt, a closure and, get the patient optimized from a nutritional standpoint and come back and fight another day for a revision if one is necessary. There is a case, a report from Switzerland that mentioned a 39-year-old [00:28:00] smoker who presented six years after gastric bypass with a perforated marginal ulcer, septic and unstable. This is kind of reminiscent of a, a board question they might give you, and they really wanna rattle your cage and see what you would do. And it's important to remember that you can always fall back on the surgical principles of, controlling the perforation and, placing tubes and, enteral access and drainage in order to, come back and fight another day, so to say. So given the extent of perforation in this particular patient and her instability, they left the patient in discontinuity with a G-tube placed in the gastric remnant and damage control. After stabilization and, and nutritional optimization, they restored the gastrojejunostomy nine weeks later, and the patient did well. So this is an extreme case, but it just goes to show you that you can get yourself out of trouble, fall back on the surgical principles, and temporize the patient for a time and a place when you can provide that [00:29:00] definitive resection and anastomosis or bringing the bowel into continuity. Pretty good outcome for this patient. Have you ever had to do this, Dr. Barney? no. Si-similar to Adrian, I, I've never had to do a GJ revision for an acute perforated marginal ulcer. but for most patients, all you need to do, as we mentioned, is primary closure, do an omental patch that buttresses. This is safe, this is effective, it controls the spillage. You leave a drain, and this is well-supported in our literature for this patient, let's assume we gave them this standard approach. What would her postoperative care look like? So th-this patient might need ICU level care, given the initial sepsis, although that's not one hundred percent needed. we're gonna continue the PPI and the antibiotics until the clinical picture improves. now what about feeding? I will typically initiate a liquid, diet very early, sometimes one to three days after surgery based on their clinical [00:30:00] status. I will sometimes get a water-soluble contrast study if, if I was concerned about the repair. but if not, I'll usually forego that and just follow the drain output. there's a leak after the primary repair, then you're probably looking at parenteral nutrition or trying to get a distal, or a remnant feeding tube to help, optimize nutrition. And postoperatively, you can go back in if need be, after the modifiable risk factors have optimized, including smoking, NSAIDs, immunosuppressants, H. pylori, et cetera makes sense. Now, what is her long-term risk for a recurrent ulcer, Dr. Dan? It's actually quite substantial, Katie. We see recurrence in about 10 to 30% of patients after surgical revision of the GJ for a perforated ulcer, and about 25 to 40% after a suture repair of the perforation. So this is where that aggressive medical and behavioral management therapy earns its keep. You've got to make sure that, patients on PPIs, absolutely no NSAIDs, , [00:31:00] intensive smoking cessation support, not being exposed to smoking or vaping or other ulcerogenic factors, and close follow-up with a low threshold to reevaluate endoscopically and, ensure that, the patient's treated appropriately Yeah. And then one more risk stratification point for smoking that lands well with patients is that studies find that patients who quit smoking within a year of their gastric bypass had a reoperation rate three times that of those who quit more than a year before their bariatric consult. the bottom line is that quitting matters and quitting early matters even more and quitting for good good. Yes Quitters always win And I th- I think it's important to mention that data show that about 70% of patients who quit just for the sake of having the surgery will start smoking again. In our practice, we will not consider you for a gastric bypass if you have [00:32:00] not quit for more than a year before your initial evaluation So would you guys test them with a serum cotinine test a year out and then again right before the surgery? So if the patient tells me they're smoking, I don't get the initial test. I know it's gonna be positive. I get one preoperatively. If the patient doesn't smoke per their report, I don't trust anybody, they will get a nicotine and cotinine test, and sometimes we find out that they're just saying what they want you to hear Yeah. Our program is a zero tolerance for, smoking So of course in my state takes a while for patients to get through the process, but they get checked twice in the workup process. So a lot of times when they call to make their appointment, they get told by our access center, "You have to be nicotine free." So people have already stopped smoking before they're ever scheduled, then they get tested twice in the, in that course of their workup process to confirm negativity Great. Thank you, guys. Now we've talked through three very different presentations. Now as we wrap up, what are some [00:33:00] key takeaways, Dr. Johnson-Mann? prevention, prevention, right? So this, you don't have an issue if you just prevent the problems. So all of that, the efforts of prevention starts before surgery. So you get a screen and treat for H. pylori, , but it is worth to acknowledge that the evidence on that is contested. , You should counsel patients about smoking, NSAID avoidance, and I go into great detail about NSAIDs, and I include prescription NSAIDs, I include Toradol, I include topical NSAIDs, the whole shebang, as well as postoperative PPI therapy. may not realize, that smoking nicotine or nicotine products after bypass increases ulcer risk or that they can't casually just take ibuprofen for a headache. So I really, I spend a lot of time harping on this with patients Yeah, and I think once an ulcer presents, we wanna follow it symptomatically and endoscopically. even if symptoms has improved, we do wanna document healing. and remember to treat the anatomy, not just the acid, or not even just assuming that acid caused this. look for [00:34:00] visible suture materials at the anastomosis. Measure the size of your pouch when you're doing the endoscopy and see if the problem is that you have a large pouch. Take a good look for any evidence of gastro-gastric fistulae. and then obviously, if you have a stricture associated with the ulcer, that's gonna be a higher risk patient for needing intervention. And know when medical and endoscopic therapy have run their courses and, surgical intervention is warranted. If an ulcer hasn't healed after treating the underlying cause with, continuous PPIs for months, we've mentioned six months, we mentioned 12 months, that's a refractory ulcer and should be evaluated by a surgeon for, surgical intervention. Sometimes you can't identify , the etiology, the offending agent, and when you perform surgery, you quickly identify that something is off, that there may be blood supply issues or there may be a foreign body , that is causing this chronic condition. But go in, into it with, , eyes open. You know, [00:35:00] revisional surgery for refractory marginal ulcers can carry a significant risk for short-term complications postoperatively, and of course, as we mentioned, long-term risk for recurrent ulceration. Another key takeaway, , in all seriousness, is that, , part of the reason that I have, , decreased the amount of gastric bypass I do in my practice is because of long-term postoperative issues, , including, , marginal ulceration. It's a very serious and difficult, , condition for patients to live with. And while other anastomotic procedures, , still carry a risk, it may be a much lower risk. So SADI, great option, and, , our generation is to forge the way forward and figure out other, , endoscopic and surgical, , techniques which may have, , better and more favorable rates of, , ulceration and other complications. So those are things to think about for the people listening to this, , podcast and, , try to figure out a better way and, , evolve our field. Absolutely. Now what about the emergency cases, [00:36:00] Dr. Martin? these are actually usually more straightforward. So peritoneal signs, free air, either on x-ray or your CAT scan usually means you're going to the operating room. , You don't wait on imaging if the patient's unstable. but if they are stable, you can start by resuscitating, giving antibiotics, , start a PPI, but then you're gonna take them to the operating room to fix that perforation. , The decision between patch and revision is made intraoperatively, although it should be extremely rare that you need to do a revision for these. It's almost always primary closure of the small perforation, omental patch, and a drain. , And these, remember, again, these are very amenable to a laparoscopic approach, so you don't need to commit them to a full laparotomy to fix a five-millimeter hole at the anastomosis. Great. Now, marginal ulcers remain one of the most challenging complications we face in bariatric surgery. They're preventable to some degree, treatable medically in the majority of cases, occasionally they [00:37:00] force us into complex decisions about escalation and revision Exactly, Katie. And the key is individualization, precision therapy. You gotta risk stratify your patients to set appropriate expectations. , Absolutely. We should also always have a regular line of communication with our colleagues in GI, , as they oftentimes are helping with endoscopies on our patients, or may be the first person to see our patients, , and/or a patient who's unattached to the program that we're affiliated with. So shared decision-making about when to pursue endoscopy versus surgery, clear discussions about optimizing risk factors, and honest conversations about prognosis is how we overall improve our outcomes. All right. Well, that was a great discussion. , I wanna thank everyone for joining us on this episode of Behind the Knife. Remember, marginal ulcers may be common, but with thoughtful management, they can be, , treated. Most patients do well. , And as always, we thank everyone for tuning in, and, one, two, [00:38:00] three. Dominate the the day. the Dominate the marginal ulcer