Bariatric Complications for the Acute Care Surgeon: Perforated Marginal Ulcer After a Roux-en-Y Gastric Bypass

A marginal ulcer occurs at or near a gastrojejunostomy anastomosis on the jejunal mucosa after gastric bypass surgery.1, 2 Incidence can range from 0.6 to 25 per cent with 83 to 95 per cent presenting within 12 months from their gastric bypass surgery.1 Patients present clinically with a history of gastric bypass along with risk factors such as smoking, nonsteroidal anti-inflammatory drugs use, and Helicobacter pylori infection.2 Often times, patients describe nonspecific symptoms such as epigastric pain, nausea, vomiting, and/or dysphagia.1 Medical management includes protein-pump inhibitors, sucralfate, smoking sensation, and endoscopic surveillance.1 Patients treated with medical management have improved symptoms approximately 68 per cent of the time.2 Whereas the perforation rate is only 1.4 per cent, general surgeons, especially in the rural areas, will continue to have to acutely manage this bariatric emergency, given that 20 per cent of patients with marginal ulcers initially present with perforation.1, 2 Revision of the gastrojejunostomy is the definitive management of a perforated marginal ulcer; however, the literature presently recommends an omental patch repair in the emergent setting.3 This case is of a perforated marginal ulcer which was surgically managed with revision of the gastrojejunostomy in the emergent setting. [...]a hemodynamically stable patient with a perforated marginal ulcer can be considered for a gastrojejunostomy revision in the emergent setting.