Higher occurrence of marginal ulcers RYGB compared with OAGB

Marginal ulcers (MU) occurred at a relatively high rate after Roux-en-Y gastric bypass (RYGB) compared with one-anastomosis gastric bypass (OAGB), according to a study by researchers from the Kasr Alainy Medical School, Cairo University, Cairo, Egypt. They noted that type 2 diabetes mellitus (T2DM) and the RYGB procedure were significant predictors of MU after adjusting for the confounding factors.

The authors noted that despite the success of RYGB, MU has been recognised as one of the more significant postoperative complications with a reported incidence ranging from 0.6% to 25%. Although the pathophysiology of MUs is not fully understood, contributing factors and variable risk factors include acid exposure, ischemic changes, smoking and infection with Helicobacter pylori, have been implicated as contributing factors to MU.

As OABG has emerged as the third most popular procedure, concerns have emerged for MU risk after OAGB. With a lack of data of MU incidence post-OAGB, their study aimed to assess the incidence of MU following both surgical procedures and to determine the potential risk factors for the occurrence of MU.

Outcomes

This study included 62 adult patients who underwent primary RYGB (n=31) or primary OAGB (n=31) between January 2020 and December 2021 and were assessed for the occurrence of MU two years after surgery. There were no significant differences in baseline data between the two groups (age, BMI, co-morbidities).

The median surgery time for RYGB was higher than that of OAGB, but not statistically significant. In terms of pouch length (cm), RYGB had a median pouch length of 7.1, while OAGB presented a significantly larger median pouch length of 17 (p<0.001). The early postoperative complications rate in the RYGB group was 6.5% (n=2)), while that of the OAGB group was 3.2% (n=1), but was not statistically significant (p=0.554).

Non-statistically significant higher weight loss was seen in the OAGB group during all follow-up time points (p>0.05). Regarding the 2-year comorbidities remission rates, RYGB and OAGB demonstrated T2DM remission rates of 62.5% and 66.7%, respectively (p=0.872). For hypertension remission, RYGB and OAGB exhibited rates of 81.8% and 88.9%, respectively (p=0.660). The remission rates for dyslipidaemia were 90.9% and 95%, respectively, in the two groups (p=0.607).

The prevalence of MU in RYGB patients was 19.4%, whereas in OAGB patients, it was significantly lower (3.2%), with a statistically significant difference (p=0.045). Comparing patients with MUs to those who did not develop MUs revealed a statistically significant difference in the incidence of abdominal symptoms, including epigastric pain, with 57.1% of patients in the MU group experiencing this symptom compared to 12.7% in the non-MU group. Other symptoms, such as vomiting, hematemesis and melena, were exclusively observed in the MU group but not in the non-MU group. A substantial proportion of patients without MUs (87.3%) reported no abdominal symptoms, compared to 28.6% in the MU group, indicating a significant difference in symptomatic presentation (p<0.001).

Proton pump inhibitor (PPI) use was significantly higher in the MU group (71.4%) compared to the non-MU group (23.6%, p=0.009). All patients with MU were smokers (100.0%) compared to 32.7% in the non-MU group (p<0.001). Chronic use of NSAIDs is significantly higher in the MU group (14.3%) compared to none in the non-MU group (p=0.005). Infection with Helicobacter pylori did not appear to be significantly associated with marginal ulcers in this cohort (p=0.317). The median pouch length was significantly longer in the MU group (12.9cm) compared to the non-MU group (6.4cm), with a highly significant difference (p<0.001).

The univariable binary logistic regression analysis for potential predictors of MU occurrence in patients who underwent bypass surgery revealed that the presence of T2DM, epigastric pain, and PPI use had statistically significant associations with MU occurrence (p=0.002, 0.01 and 0.02, respectively). There was a marginal trend toward the association of RYGB with the occurrence of MU (p=0.076). In the multivariate analysis, the presence of T2DM and the type of surgery stood out as significant predictors (p=0.013 and 0.045, respectively).

“Although type 2 diabetes mellitus and the RYGB procedure were identified as significant predictors of MU after adjustment for confounding factors, these findings should be interpreted with caution, given the small sample size,” they concluded. “Further studies with larger cohorts are needed to confirm these associations and provide a more comprehensive understanding of MU risk after bypass surgery.”

The findings were reported in the paper, ‘Incidence of marginal ulcer after one anastomosis gastric bypass versus Roux-en-Y gastric bypass: a comparative study’, published in BMC Surgery. To access this paper, please click here