Laparoscopic Conversion of Roux-en-Y Gastric Bypass to Sleeve Gastrectomy for Intractable Marginal Ulcer

Marginal ulceration (MU) is a well-known complication of Roux-en-Y gastric bypass (RYGB) with a rate of 1%–16% in most recent series [ 1 Patel R.A. Brolin R.E. Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009; 5: 317-322 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar , 2 Rasmussen J.J. Fuller W. Ali M.R. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc. 2007; 21: 1090-1094 Crossref PubMed Scopus (200) Google Scholar , 3 Steinemann D.C. Bueter M. Schiesser M. Amygdalos I. Clavien P.A. Nocito A. Management of anastomotic ulcers after Roux-en-Y gastric bypass: results of an international survey. Obes Surg. 2014; 24: 741-746 Crossref PubMed Scopus (33) Google Scholar , 4 Higa K.D. Boone K.B. Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients—what have we learned?. Obes Surg. 2000; 10: 509-513 Crossref PubMed Scopus (538) Google Scholar ]. Several predisposing factors have been identified, either related to the surgical technique or to the patient. Surgical technique-related factors include the shape and the volume of the gastric pouch that may produce excess acid secretion, a gastrogastric fistula, local tissue ischemia due to anastomotic tension, and the presence of foreign bodies such as nonabsorbable sutures. Patient-related factors include smoking, Helicobacter pylori, use of NSAIDs, and lack of proton pump inhibitor prophylaxis [ 1 Patel R.A. Brolin R.E. Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009; 5: 317-322 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar , 2 Rasmussen J.J. Fuller W. Ali M.R. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc. 2007; 21: 1090-1094 Crossref PubMed Scopus (200) Google Scholar , 3 Steinemann D.C. Bueter M. Schiesser M. Amygdalos I. Clavien P.A. Nocito A. Management of anastomotic ulcers after Roux-en-Y gastric bypass: results of an international survey. Obes Surg. 2014; 24: 741-746 Crossref PubMed Scopus (33) Google Scholar , 4 Higa K.D. Boone K.B. Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients—what have we learned?. Obes Surg. 2000; 10: 509-513 Crossref PubMed Scopus (538) Google Scholar , 5 Sapala J.A. Wood M.H. Sapala M.A. Flake Jr, T.M. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg. 1998; 8: 505-516 Crossref PubMed Scopus (202) Google Scholar , 6 Azagury D.E. Abu Dayyeh B.K. Greenwalt I.T. Thompson C.C. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy. 2011; 43: 950-954 Crossref PubMed Scopus (131) Google Scholar ]. H. pylori infection eradication, proton pump inhibitors, and sucralfate are the first-line treatments for MU and are effective in 68%–88% of cases [ 1 Patel R.A. Brolin R.E. Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009; 5: 317-322 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar , 3 Steinemann D.C. Bueter M. Schiesser M. Amygdalos I. Clavien P.A. Nocito A. Management of anastomotic ulcers after Roux-en-Y gastric bypass: results of an international survey. Obes Surg. 2014; 24: 741-746 Crossref PubMed Scopus (33) Google Scholar , 7 Hedberg J. Hedenström H. Nilsson S. Sundbom M. Gustavsson S. Role of gastric acid in stomal ulcer after gastric bypass. Obes Surg. 2005; 15: 1375-1378 Crossref PubMed Scopus (76) Google Scholar ]. In up to one third of patients, however, operative revision is required for an intractable MU. Intractability can be defined as failure to relieve symptoms and heal the ulcer after at least 3 months of aggressive medical therapy [ [1] Patel R.A. Brolin R.E. Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009; 5: 317-322 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar ]. We report a case of a MU refractory to medical treatment, which was laparoscopically converted from RYGB to sleeve gastrectomy (SG). This surgical option has been reported in the literature, but not for MU [ 8 Dapri G. Cadière G.B. Himpens J. Laparoscopic conversion of Roux-en-Y gastric bypass to sleeve gastrectomy as first step of duodenal switch: technique and preliminary outcomes. Obes Surg. 2011; 21: 517-523 Crossref PubMed Scopus (22) Google Scholar , 9 Zurita Mv LC Tabari M. Hong D. Laparoscopic conversion of laparoscopic Roux-en-Y gastric bypass to laparoscopic sleeve gastrectomy for intractable dumping syndrome and excessive weight loss. Surg Obes Relat Dis. 2013; 9: e34-e37 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar , 10 Simper S.C. Erzinger J.M. McKinlay R.D. Smith S.C. Laparoscopic reversal of gastric bypass with sleeve gastrectomy for treatment of recurrent retrograde intussusception and Roux stasis syndrome. Surg Obes Relat Dis. 2010; 6: 684-688 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar ].