CE for Nurses: Late Surgical Complications of Roux-en-Y Gastric Bypass: Afferent Limb and Marginal Ulcer

| October 1, 2016

This CE is currently expired.

*This is a Complimentary Clinical Nursing Education Activity*

Nurses: Earn 1 Contact Hour.

Complimentary Continuing Education Course: Late Surgical Complications of Roux-en-Y Gastric Bypass: Afferent Limb and Marginal Ulcer

Take the test at http://tinyurl.com/BTCEOctober2016
Participants must read the designated article and take, submit, and pass the post-test by October 1, 2017. Participants must answer at least
70% of the post-test questions correctly to pass and receive credit for the activity. Upon successful completion of the post-test, participants will receive a certificate of completion.

Course Overview: Afferent limb and marginal ulcers are described in bariatric educational courses and literature as possible late complications following bariatric surgery. Recognition of these complications can be a challenge because patient presentation may vary from subtle to overt symptoms. This educational program will describe the etiology, signs and symptoms, nursing assessment, and medical and surgical interventions to address both afferent limb and marginal ulcer diagnoses.

Course Description: This educational program is designed to educate, through independent study, nursing clinicians who care for the post-operative bariatric surgical patient on assessment and nursing interventions for the post-operative patient with an afferent limb and marginal ulcer following bariatric surgery. This article will also include diagnosis and treatment of each.

Course Objectives: Upon completion of this program, the participant should be able to:
1.) List the common and uncommon presenting symptoms associated with a patient who has an afferent limb following bariatric surgery.
2.) List the common and uncommon presenting symptoms associated with a patient who has a marginal ulcer following bariatric surgery.
3.) Explain the common causes and risk factors associated with afferent limb and marginal ulcers following bariatric surgery.
4.) Identify the essential nursing assessment skills when assessing a patient for afferent limb and marginal ulcer.
5.) Discuss the appropriate surgical, medical, and nursing interventions for a patient with post-operative afferent limb and marginal ulcer.

Completion Time: This educational activity is accredited for a total of 1.0 contact hour.

Target Audience: This accredited program is intended for nurses who treat patients undergoing surgical treatment for obesity.

Provider: This educational program is provided by Matrix Medical Communications. Provider approved by the California Board of Registered Nursing, Provider Number 14887, for 1.0 contact hour.

About the Instructors: Leonardo Claros, MD, FACS, FASMBS, and Thomas E. Sonnanstine IV, MD, FACS, are board certified bariatric surgeons.
Dr. Claros is Chief, Bariatric Section, Director, Weight Management Center, Clinical Assistant Professor of Surgery, St. Luke’s University and Health Network in Allentown, Pennsylvania. Dr. Sonnanstine is Medical Director, OhioHealth Surgical Weight Management, Riverside Methodist Hospital, in Columbus, Ohio.
Disclosures: Drs. Claros and Sonnanstine report no conflicts of interest relevant to the content of this article.

Support for this educational activity is provided by Ethicon

Provider Contact Information: Angela M. Saba, Matrix Medical Communications, 1595 Paoli Pike,Suite 201, West Chester, PA 19380; E-mail: asaba@matrixmedcom.com

Complimentary Continuing Education Course: Late Surgical Complications of Roux-en-Y Gastric Bypass: Afferent Limb and Marginal Ulcer

by Leonardo Claros, MD, FACS, FASMBS, and Thomas E. Sonnanstine IV, MD, FACS
Dr. Claros is Chief, Bariatric Section, Director, Weight Management Center, Clinical Assistant Professor of Surgery, St. Luke’s University and Health Network in Allentown, Pennsylvania. Dr. Sonnanstine is Medical Director, OhioHealth Surgical Weight Management, Riverside Methodist Hospital, in Columbus, Ohio.

ABSTRACT
With the tremendous growth in Bariatric Surgery over the past 15 years, healthcare professionals are seeing more and more patients who have had Roux-en-Y gastric bypass. The diagnosis and evaluation of long-term complications is often challenging and requires a good understanding of both the surgical anatomy as well as variations in surgical technique. The purpose of this article will be to familiarize the practitioner with the diagnosis and treatment of complications involving the afferent Roux limb and marginal ulceration.

Bariatric Times. 2016;13(10):10–14.


Introduction
Since its introduction by Mason and Ito in the 1960s,[1] the Roux-en-Y gastric bypass (RYGB) has gained a foothold in popularity and effectiveness in the treatment of obesity, obesity-related comorbidities, and metabolic disease. According to the latest estimates, RYGB represents the second most performed bariatric procedure in the United States (23.1%). Sleeve gastrectomy currently holds the number one position (53.8%).[2]
Whether involved in the performance of the primary operation or in the care of patients postoperatively, it is important for the healthcare professional to have an understanding of potential long-term complications that can occur in the early and late postoperative period following RYGB. In this article, we discuss the following two late postoperative complications: afferent Roux limb and marginal ulcer.

Roux-en-Y Gastric Bypass: Procedure and Surgical Complications
Procedure. The construction of the Roux limb lies at the center of the operation, both literally and figuratively. Accoricding to the the American Society for Metabolic and Bariatric Surgery (ASMBS), RYGB is comprised of the following steps:[3]
1.    A small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach.
2.    The first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch.
3.    The top portion of the divided small intestine is connected to the small intestine further down.

The technical performance of RYGB has many variations described in the literature (e.g., end-to-end stapler technique, hand-sewn gastrojejunostomy)[4] These technical and anatomical differences must be considered by the healthcare provider in the differential diagnoses of complications postoperatively.

Complications. Postoperative bariatric surgery complications can be divided into two categories: “Early” and “Late.” For the purposes of this discussion, we will define early complications as those occurring within 30 days postoperatively.[5]

Early complications are typically more obvious in their presentation and, thus, often lead to quicker diagnosis and surgical treatment. Early surgical postoperative complications following RYGB include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction, and incorrect Roux limb reconstructions.[6]

Late complications often have a more inconspicuous presentation, which may cause the patient to suffer from and present with symptoms that are non-specific and difficult to diagnose. Oftentimes, patients will have presented to a primary care physician or a general surgeon before ultimately finding their way back to the bariatric surgery practice. They may have undergone numerous noninvasive and invasive diagnostic studies before finally encountering a provider who truly understands the diversity of RYGB anatomy.

Leaks from either the gastro-jejunal anastomosis or jejunal-jejunal anastomosis will typically be of an acute nature. An internal hernia will lead to either a partial or complete small bowel obstruction of either indolent or acute presentation.

Marginal ulcers, discussed elsewhere in this article, will have acute and/or chronic presentation.

The Afferent Roux Limb
The bariatric surgery literature reveals a paucity of discussion of both the technical aspects of the afferent Roux limb and the potential complications therein. Diagnosis of complications of the afferent Roux limb are typically made after other more obvious causes of chronic complications have been evaluated and excluded. While complications of the afferent Roux limb are few and rarely discussed, they can be a real source of discomfort and decreased quality of life for the bariatric surgery patient. Such complications will likely be diagnoses of exclusion after other causes, such as a hiatal hernia, marginal ulcer, and internal hernia, have been evaluated and ruled out.

An afferent Roux limb is not present in all RYGB cases. It occurs in an estimated 0.2 to 1.0 percent of patients after gastrectomy with a Billroth II or Roux-en-Y reconstruction.[7] From an anatomical perspective, when present, the afferent Roux limb is directly adjacent to the gastro-jejunal anastomosis (GJA). The afferent Roux limb may be present in an end (pouch)-to-side (jejunum) GJA (Figure 1). Specifically, the anastomosis of the gastric pouch is made to the side of the proximal-most portion of the Roux limb, leaving a blind-end of jejunum that must be stapled or sutured closed at the time of surgery. Imagine a candy cane—the afferent Roux limb is the short end of the candy cane with the gastric pouch attached to the apex of the hook. An afferent Roux limb will not exist if the gastric pouch is anastomosed, stapled or sutured, in an end-to-end fashion to the Roux limb.

During creation of an end-to-side GJA, whether stapled or sutured, the goal should be to leave the afferent limb as short as possible. Any unnecessary length of afferent Roux limb can act as a blind end into which consumed liquids, food, or oral secretions may preferentially settle and lay stagnant. With operative attention and diligence, it should be possible to leave the total length of the afferent Roux limb less than 2 to 3 cm. Even with such small length, this tissue may elongate over time and become symptomatic.

Signs and symptoms. Complications involving the afferent Roux limb, except for an acute leak of the staple/suture line or a perforation of the afferent limb via instrumentation (nasogastric or orogastric tube), are typically chronic in nature. It is unusual for a gastric bypass patient to experience nausea and/or vomit recently ingested food, since there is no gastric reservoir and the small bowel propels food distally quite rapidly. Afferent limb patients will typically present with complaints of nausea, gastroesophageal reflux disease (GERD), heartburn, abdominal cramping and/or pain, or regurgitation of food or liquids that were consumed hours before.[8,9] Classically, once the vomiting has occurred, the pain and nausea resolve. It is the distention of the afferent limb that causes the nausea and pain.[8]

Diagnosis. Initial work-up will likely consist of evaluation of the gallbladder, computed tomography (CT) scan and, perhaps, barium upper GI or upper endoscopy. Barium upper GI will demonstrate an abnormally long and preferentially filling (and slowly emptying) afferent Roux limb. Given the symptoms, this may be enough to justify proceeding to the operating for resection of the afferent limb. However, it would be advisable for the surgeon to perform an upper endoscopy as it is likely to demonstrate oral secretions or even food in the limb and the limb may be measured in length. In some cases, the mucosa of the afferent Roux limb may appear ischemic or dusky.

Treatment. While conservative management of afferent limb has been attempted with some success,[10] we believe that the only real treatment is surgery. In our experience, operatively, resection of the abnormally long afferent Roux limb is not complicated. Dissection of adhesional attachments of the efferent Roux limb to the afferent Roux limb may be necessary. The surgeon should carefully divide the underlying mesentery of the afferent limb. Use of an endomechanical staple gun with a blue cartridge is the advisable method for the transection. We have found that dissection of the limb is likely to be more difficult when in a retro-gastric position. A full inspection of the RYGB anatomy should be undertaken at the time of surgery in order to evaluate for an internal hernia or other pathology.

Leaks from either the GJA or jejunal-jejunal anastomosis will typically be of an acute nature. An internal hernia will lead to either a partial or complete small bowel obstruction of either indolent or acute presentation.

Marginal Ulceration
Marginal ulcerations can be potentially serious complications after bariatric surgery. There should be a high index of suspicion for this pathology in bariatric patients with known risk factors and specific symptoms and complaints. A diligent and thorough evaluation is warranted to potentially prevent emergency episodes due to bleeding or perforation secondary to these ulcers.

Overview. Ulcers after a bariatric surgery will be either peptic or anastomotic (marginal ulcers). Peptic ulcers occur in anatomic locations such as the distal gastric antrum or duodenum, as they would occur in people who have not had bariatric surgery. In certain bariatric procedures, such as adjustable gastric banding (AGB) and sleeve gastrectomy (SG), the incidence of peptic ulcer disease is similar to that of non-bariatric patients. However, the peptic ulcer occurs at a lower incidence after RYGB than in the general surgery population.11 In a study of over 3,000 RYGB patients, Printen et al reported a peptic ulcer incidence of 0.26 percent.[12]

Marginal ulcers (also called anastomotic ulcers due to the location where they most frequently present) after RYGB have a variable incidence (0.6–16%).[13–15] The marginal ulceration is commonly a mucosal erosion on the intestinal side of the anastomosis within the gastric pouch.[11]

The intestinal mucosa is normally not exposed to gastric acid, which gets neutralized by the alkaline biliopancreatic secretions in the duodenum. Unlike the stomach, which is resistant to acid, the intestinal mucosa has no natural barriers and is more prone to ulceration.[11] The causes of marginal ulceration after gastric bypass are multifactorial. Marginal ulcers have been associated with the following: the use of nonabsorbable suture material,[16,17] gastric pouch size greater than 50 cc,[18,19] nonsteroidal anti-inflammatory drug use (NSAIDs),[20,21] Helicobacter pylori,[22] tobacco use,[23] ischemia, Roux limb tension, and gastro-gastric fistula (i.e., communication within the newly created gastric pouch and the gastric remnant resulting in acid entering the pouch from the native stomach and contacting the jejunal side of the anastomosis). Gastro gastric fistulas have been found in one percent of all RYGB cases. In contrast, 19 percent of patients that have a marginal ulceration also have gastro gastric fistula, indicating that this kind of fistula can complicate or contribute to the development of a marginal ulcer.[24] In another study, Patel et al[25] examined a total of 2,282 consecutive patients that underwent RYGB by one surgeon from 1984 to 2006 (1,621 were open and 661 laparoscopic). They found that 112 patients (5.3%) developed marginal ulcers, and 39 (32%) of those patients required revisional surgery. Upon investigation, 28 (71.7%) of these patients also had gastro-gastric fistulas.

In our practices, it is routine to evaluate the preoperative bariatric patient with an upper endoscopy. This procedure allows the surgeon to evaluate the potential of gastrointestinal diseases, such as GERD or peptic ulcers, before surgery. Discovery of hiatal hernias in this stage or the presence of upper GI tumors or lesions, all of which are not uncommon findings, potentially influence our decision toward which operation would be best suited for each patient. We routinely take biopsies of the antrum of the stomach looking to rule out the presence of H. pylori. If the patient is positive for H. pylori, he or she is routinely treated with triple therapy including a proton pump inhibitors (PPI) and two antibiotics for two weeks. We believe treating this infection prior to the surgery will reduce the incidence of marginal ulcerations. Our incidence of marginal ulcerations is on the low end of the 0.6 to 16 percent range as reported in the literature, and we believe that this is because we are conducting tests and proactively treating these patients for H. pylori. Marginal ulcer is not an uncommon complication; two percent present within the first two months after surgery, but it can develop as late as 10 years after the operation.[26]

Symptoms and presentation. Patients with marginal ulcers will usually present with burning, upper epigastric pain that might exacerbate with eating.[27] Some patients may complain of substernal chest pain or pain that radiates to the back.[5]

Nausea, vomiting, and food intolerance are also commonly seen with marginal ulcers.[24] Massive upper gastrointestinal bleeding, though uncomon, can also be seen as a late manifestation of untreated or unrecognized ulcer disease.[28] There should be a high index of suspicion if the patient has risk factors such as tobacco and NSAID use as well as others listed before. Weight gain can also be seen as the patients tend to snack on carbohydrate foods, which may be comforting to the ulcerated tissues.

Evaluation and diagnosis. The evaluation of a patient who presents with symptoms suggestive of ulceration is straightforward. A barium swallow could be used as a diagnostic test that is noninvasive and simple to perform, although it is not sensitive and could miss small or shallow ulcers. Upper endoscopy is the gold standard for the evaluation and diagnosis. Ulcers could be fairly large and not initially seen on the front view inspection during upper endoscopy (Figure 2, Figure 3a). Figure 3 shows an ulceration that is not initially seen in its entirety as it is located behind the lip of the gastro-jejunal anastomosis. Once the scope is advanced through the stoma, the ulcer is obvious at the three o’clock position (Figure 3b).
A common complication of marginal ulcerations is the development of strictures at the level of the anastomosis.[29] These strictures are secondary to the scarring and contraction of the inflamed tissues surrounding the ulcer. Once again, upper endoscopy could be used for the treatment of an associated anastomotic stricture or to control the bleeding in the acute setting.

Management and treatment. If an ulceration is found, the treatment usually involves the removal of the irritant that is causing it (e.g., NSAIDs or tobacco) and the prescription of either a histamine-receptor antagonist or a PPI along with a coating agent such as sucralfate. Most ulcers will heal with conservative therapy.[24] Patients should be re-evaluated by upper endoscopy in 6 to 8 weeks to reasses the ulcer.[30]

Marginal ulcers secondary to ischemia, enlarged pouches, or gastro-gastric fistula tend to present with more refractory symptoms and will often require revision surgery.[31]

Perforated marginal ulcers can safely be managed laparoscopically, especially if they are identified within the first 24 hours.[32] The absence of significant intra-abdominal adhesions in the anterior location of the anastomosis allows for relatively simple closure and omental patch.[33] In a study of 201 gastric bypass patients, Dallal et al[34] found that 3.5 percent had developed ulcer disease. Of these patients, 14 percent required operation; however, the remaining patients’ symptoms and ulcer disease resolved with medical therapy.

It is our practice to keep our patients on antacid medication postoperatively and for at least six months as we believe this might decrease the incidence of marginal ulcers. It should be noted, however, that not every practice routinely prescribes such medications. If the patient has failed conservative management, despite eliminating the associated risk factors, a surgical revision that usually involves resection of the gastro-jejunal anastomotic area containing the ulcer, is warranted. These procedures can be technically challenging and should be reserved for surgeons experienced in revisional surgery.

Conclusion
The diagnosis and evaluation of afferent limb is often challenging and requires a good understanding of both the surgical anatomy as well as variations in surgical technique. Healthcare providers should also be familiar with the typical signs and symptoms: nausea, gastroesophageal reflux disease (GERD), heartburn, abdominal cramping and/or pain, or regurgitation of food or liquids.

Marginal ulcerations are not uncommon complications after gastric bypass surgery. There should be a strong emphasis on the bariatric program, performing these procedures, to educate the patients with regards to the risks associated with smoking, drinking alcohol and the utilization of NSAIDs postoperatively.

From the technical point of view, the surgeon should perform a careful and thorough dissection to completely exclude the fundus and to minimize the size of the pouch in order to limit the amount of acid production by the parietal cells that might lead to the formation of these ulcers. Surgical technique can also prevent tension on the anastomosis and ischemia, which has been also associated with this complication as well. The history of smoking or tobacco use remains, in our opinion, the highest independent factor for ulcer persistence. This, and the presence of other risk factors, will make the treatment of this problem more challenging and may lead to an increase in recurrence.

References
1.    Mason, EE and Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47:1345-51.
2.    https://asmbs.org/resources/
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3.    https://asmbs.org/patients/
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4.    Nguyen NT, Scott-Conner CEH (eds.), The SAGES Manual: Volume 2: Advanced Laparoscopy and Endoscopy, Third Edition. Springer New York, 2012
5.    Claros L, Shikora S. Complications of bariatric surgery. In: Gerard E. Mullin, Lawrence J. Cheskin, Laura E. Matarese (eds.) Integrative Weight Management: A Guide for Clinicians. Springer Science & Business, 2014
6.    Griffith PS, Birch DW, Sharma AM, Karmali S. Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity. Can J Surg. 2012;55(5):329–336.
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11.    Shikora SA, Claros L, Kim JJ, Tarnoff ME. Chapter 38. Late complications: ulcers, stenosis, and fistula. In Pitombo C, Jones KB, Higa K, Pareja J. Obesity Surgery: Principles and Practice. The McGraw-Hill Companies, Inc. 2008.
12.    Printen KJ, LeFavre J, Alden J. Bleeding from the bypassed stomach following gastric bypass. Surg Gynecol Obstet.1983;156: 65–66.
13.    Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004 240(3): 416–424.
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16.    Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg. 1999;9(1):22–27; discussion 28.
17.    Sacks BC, Mattar SG, Qureshi FG, Eid GM, Collins JL, Barinas-Mitchell EJ, Schauer PR, Ramanathan RC. Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006;2(1):11–16.
18.    Printen KJ, Scott D, Mason EE. Stomal ulcers after gastric bypass. Arch Surg. 1980;115(4):525–527.
19.    Jordan JH, Hocking MP, Rout WR, Woodward ER. Marginal ulcer following gastric bypass for morbid obesity. Am Surg. 1991;57(5):286–288.
20.    Wallace JL, Granger DN. Pathogenesis of NSAID gastropathy: are neutrophils the culprits? Trends Pharmacol Sci. 1992;13(4):129–131.
21.    Kurata JH, Nogawa AN. Meta-analysis of risk factors for peptic ulcer. Nonsteroidal antiinflammatory drugs, Helicobacter pylori, and smoking. J Clin Gastroenterol. 1997;24(1):2–17.
22.    Schirmer B, Erenoglu C, Miller A. Flexible endoscopy in the management of patients undergoing Roux-en-Y gastric bypass. Obes Surg. 2002;12(5):634–638.
23.    Kean J. The effects of smoking on the wound healing process. J Wound Care. 2010;19(1):5–8.
24.    Gumbs AA, Duffy AJ, Bell RL. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis. 2006;2(4):460–463.
25.    Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5(3):317–322.
26.    Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, Wolfe L. Stomal complications of gastric bypass: incidence and outcome of therapy. Am J Gastroenterol. 1992;87(9):1165–1169.
27.    Kang X, Zurita-Macias L, Hong D, Cadeddu M, Anvari M, Gmora S. A comparison of 30-day versus 90-day proton pump inhibitor therapy in prevention of marginal ulcers after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016;12(5):1003–107.
28.    Sidani S, Akkary E, Bell R. Catastrophic bleeding from a marginal ulcer after gastric bypass. JSLS. 2013;17(1):148–151.
29.    Rohini R Vanga, Raj Majithia, Frederick C Finelli, Timothy R Shope, Timothy R Koch. Anastomotic stricture formation after Roux-En-Y gastric bypass surgery: a single center retrospective cohort study. J Gastroenterol Hepatol Res. 2013;2(12).
30.    Lee JK, Van Dam J, Morton JM, Curet M, Banerjee S. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104(3):575–582; quiz 583.
31.    Livingston EH. Complications of bariatric surgery. Surg Clin North Am. 2005;85(4):853–868, vii.
32.    Goitein D, Papasavas PK, Gagné DJ, Caushaj PF. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2005;15(6):880–882.
33.    Moon RC, Teixeira AF, Goldbach M, Jawad MA. Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center. Surg Obes Relat Dis. 2014;10(2):229–234.
34.    Dallal RM, Bailey LA. Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis. 2006;2(4):455–459.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

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