Endoscopic suture removal at gastrojejunal anastomosis after Roux-en-Y gastric bypass to prevent marginal ulceration

Abstract 

Background

After Roux-en-Y gastric bypass (RYGB) surgery, marginal ulcers develop in 3–23% of patients. Marginal ulcers can occur secondary to the use of nonabsorbable sutures to create the gastrojejunostomy. The suture can elicit a foreign body reaction that exposes it to the gastric lumen, irritating the mucosa. Surgical removal is mandated when medical therapy fails to resolve matters. Because endoscopic removal would be less invasive than laparotomy, a technique for the endoscopic removal of the suture was devised. Presented are the results of 6 patients who underwent this procedure.

Methods

A computer search of all patients who had undergone laparoscopic RYGB was done and found 6 women who had undergone endoscopic suture removal. After a double-lumen endoscope was inserted through the mouth, a grasper was used to placed the suture under tension before transecting it with blunt-tip endoshears. The suture was then removed without difficulty. All patients were evaluated at 2 weeks and 6 months postoperatively.

Results

Of the patients who underwent laparoscopic RYGB between June 2003 and June 2005 and presented with epigastric pain, 6 women underwent endoscopic stitch removal. These women had a mean age of 57 years, a mean initial body mass index of 55 kg/m², and had undergone laparoscopic RYGB a mean of 18 months before presentation. The patients, who had experienced new-onset epigastric pain and “heartburn,” underwent endoscopic examination of the stomach, which showed visible suture at the gastrojejunal anastomosis, no ulceration, and edema, and underwent suture removal. No complications developed. At 6 months of follow-up, all patients were without symptoms and had normal findings on upper endoscopy.

Conclusion

The results of our study have shown that endoscopic suture removal is a feasible and effective means of treating epigastric pain and preventing the suture-induced marginal ulcers that can occur after RYGB.

Keywords: Gastric bypass, Morbid obesity, Nonabsorbable suture, Gastrojejunal anastomosis, Marginal ulceration, Stenosis, Bleeding, Therapeutic algorithm