Surgical Endoscopy

, Volume 32, Issue 3, pp 1215–1222 | Cite as

The natural history of perforated marginal ulcers after gastric bypass surgery

  • Maria S. Altieri
  • Aurora Pryor
  • Jie Yang
  • Donglei Yin
  • Salvatore Docimo
  • Andrew Bates
  • Mark Talamini
  • Konstantinos Spaniolas



Although perforated marginal ulcers (pMU) following Roux-en-Y Gastric Bypass (RYGB) represent a surgical emergency, the epidemiology and outcome of this condition is not well understood. The purpose of this study was to evaluate incidence of pMU following RYGB and assess the natural history of this complication.


The SPARCS administrative database was used to identify patients undergoing RYGB between 2005 and 2010. With the use of a unique identifier, we followed patients up to 2014 for subsequent admission and re-intervention (repair or revision) for perforated MU. Groups were compared using Chi square tests with exact p values based on Monte Carlo simulation, t test with unequal variances, and the Wilcoxon rank-sum test when appropriate.


We identified 35,080 RYGB patients; 292 patients (0.83%) developed pMU 937 (443–1546) days following RYGB [Median (Q1–Q3)]. Among these 292 patients, tobacco use was present in one-third of patients. Repair of the perforation was performed in 115 patients, while anastomotic revision was reported in 64. Patients who underwent revision were more likely to have respiratory complications. Hospital length of stay was significantly longer for patients managed with RYGB revision (Median, Q1–Q3:7, 5–14, vs 6, 4–7, days, p = 0.001). Recurrence of marginal ulcer was common after either intervention (26.09% for repair and 29.69% for revision, p = 0.726).


Following RYGB, the incidence of pMU is small. Anastomotic revision for pMU is associated with prolonged length of stay compared to repair alone. Importantly, recurrence after intervention of pMU is common, suggesting possible value of a routine surveillance program for patients following pMU.


Roux-en-Y Gastric Bypass Perforated marginal ulcer 



We acknowledge the biostatistical consultation and support provided by the Biostatistical Consulting Core at School of Medicine, Stony Brook University.


No industry or other external funding was used for this research.

Compliance with ethical standards


Dr. Pryor receives honoraria for speaking for Ethicon, Medtronic, Stryker, and Gore; is a consultant for Medicines Company, Merck, and Intuitive, and has ownership interest in Transenterix. Maria S. Altieri, Jie Yang, Donglei Yin, Salvatore Docimo, Andrew Bates, Mark Talamini, Konstantinos Spaniolas have no conflicts of interest or financial ties to disclose.


  1. 1.
    Centers for Disease Control, National Center for Health Statistics (2015). Accessed 23 Feb 2017
  2. 2.
    New procedure estimates for bariatric surgery: what the numbers reveal. Connect: the official news magazine of ASMBS (2014). Accessed 14 Dec 2016
  3. 3.
    Mingrone G, Panunzi S, De Gaetano A et al (2012) Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 366:1577–1585CrossRefPubMedGoogle Scholar
  4. 4.
    Sjöström L, Narbro K, Sjöström CD et al (2007) Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 357:741–752CrossRefPubMedGoogle Scholar
  5. 5.
    Wharton S, Serodio KJ, Kuk JL, Sivapalan N, Craik A, Aarts MA (2016) Interest, views and perceived barriers to bariatric surgery in patients with morbid obesity. Clin Obes 6(2):154–160CrossRefPubMedGoogle Scholar
  6. 6.
    Sapala JA, Wood MH, Sapala MA, Flake TM Jr (1998) Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg 8(5):505–516CrossRefPubMedGoogle Scholar
  7. 7.
    MacLean LD, Rhode BM, Nohr C, Katz S, Mclean AP (1997) Stomal ulcer after gastric bypass. J Am Coll Surg 185(1):1–7CrossRefPubMedGoogle Scholar
  8. 8.
    Dallal RM, Bailey LA (2006) Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis. 2(4):455–459CrossRefPubMedGoogle Scholar
  9. 9.
    Gumbs AA, Duffy AJ, Bell RL (2006) Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis 2(4):460–463CrossRefPubMedGoogle Scholar
  10. 10.
    Rasmussen JJ, Fuller W, Ali MR (2007) Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc 21(7):1090–1094CrossRefPubMedGoogle Scholar
  11. 11.
    Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, Van Wagensveld BA (2014) Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg 24(2):299–309CrossRefPubMedGoogle Scholar
  12. 12.
    Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC (2011) Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy 43(11):950–954CrossRefPubMedGoogle Scholar
  13. 13.
    Hedberg J, Hedenstrom H, Nilsson S, Sundbom M, Gustavsson S (2005) Role of gastric acid in marginal ulcer after gastric bypass. Obes Surg 15(10):1375–1378CrossRefPubMedGoogle Scholar
  14. 14.
    Felix EL, Kettelle J, Mobley E, Swartz D (2008) Perforated marginal ulcers after laparoscopic gastric bypass. Surg Endosc 22(10):2128–2132CrossRefPubMedGoogle Scholar
  15. 15.
    Lublin M, McCoy M, Waldrep DJ (2006) Perforating marginal ulcers after laparoscopic gastric bypass. Surg Endosc 20(1):51–54CrossRefPubMedGoogle Scholar
  16. 16.
    Telem DA, Talamini M, Gesten F, Patterson W, Peoples B, Gracia G, Yang J, Zhang Q, Altieri M, Pryor AD (2015) Hospital admissions greater than 30 days following bariatric surgery: patient and procedure matter. Surg Endosc 29(6):1310–1315CrossRefPubMedGoogle Scholar
  17. 17.
    Coblijn UK, Lagarde SM, de Castro SM, Kuiken SD, van Tets WF, van Wagensveld BA (2016) The influence of prophylactic proton pump inhibitor treatment on the development of symptomatic marginal ulceration in Roux-en-Y gastric bypass patients: a historic cohort study. Surg Obes Relat Dis 12(2):246–252CrossRefPubMedGoogle Scholar
  18. 18.
    Moon RC, Teixeria AF, Goldbach M, Jawad MA (2013) Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center. Surg Obes Relat Dis 10(2):229–234CrossRefPubMedGoogle Scholar
  19. 19.
    Wendling MR, Linn JG, Keplinger KM et al (2013) Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass. Surg Endosc 27(2):384–389CrossRefPubMedGoogle Scholar
  20. 20.
    Patel RA, Brolin RE, Gandhi A (2009) Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 5(3):317–322CrossRefPubMedGoogle Scholar
  21. 21.
    Wheeler AA, de la Torre RA, Fearing NM (2011) Laparoscopic repair of perforated marginal ulcer following Roux-en-Y gastric bypass: a case series. J Laparoendosc Adv Surg Tech A 21(1):57–60CrossRefPubMedGoogle Scholar
  22. 22.
    Evans JP, Smith R (1997) Predicting poor outcome in perforated peptic ulcer disease. Aust N Z J Surg 67(11):792–795CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Maria S. Altieri
    • 1
  • Aurora Pryor
    • 1
  • Jie Yang
    • 2
  • Donglei Yin
    • 3
  • Salvatore Docimo
    • 1
  • Andrew Bates
    • 1
  • Mark Talamini
    • 1
  • Konstantinos Spaniolas
    • 1
  1. 1.Division of Bariatric, Foregut and Advanced Gastrointestinal Surgery, Department of SurgeryStony Brook University Medical CenterStony BrookUSA
  2. 2.Department of Family, Population and Preventive MedicineStony Brook University Medical CenterStony BrookUSA
  3. 3.Department of Applied Mathematics and StatisticsStony Brook UniversityStony BrookUSA

Personalised recommendations