Marginal Ulcers After Roux-en-Y Gastric Bypass: Patterns of Care, Treatment, and Outcomes from a Tertiary Referral Center

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Abstract
Background Marginal ulcers (MU) represent a common and serious complication following Roux-en-Y gastric bypass (RYGB). While most MUs heal with conservative therapy, a subset requires endoscopic or surgical intervention. This study aims to characterize management trajectories and identify predictors of perforation. Methods A retrospective review was performed to identify patients who underwent RYGB between 2008 and 2023 at a tertiary referral center and were subsequently diagnosed with MU. Baseline characteristics, management strategies, and clinical outcomes were collected. MU management was categorized as medical, endoscopic, or surgical. Continuous variables were summarized using medians with interquartile ranges (IQR), and categorical variables using frequencies and percentages. Univariate testing, multivariate regression, and time-to-event analyses were used to assess predictors of MU perforation. Results Among 2106 patients, 241 patients developed MUs (incidence 11.4%). Ulcers were identified at a median of 7.1 months (IQR 3.0–16.2) following RYGB. Most patients (77.2%) resolved with medical management, while 22.8% required escalation to endoscopic (11.2%) or surgical (11.6%) intervention. The median time from MU diagnosis to surgical intervention was 12.1 months (IQR 4.9–21.2) after excluding patients who presented with perforation at the time of MU diagnosis. Ulcer perforation occurred in 24 patients and was managed with Graham patch repair or endoscopic techniques. Multivariate analysis showed that female sex (OR 0.31; 95% CI 0.11–0.85; p = 0.035) was associated with a decreased risk of perforation, while smoking resumption at 6 months postoperatively (OR 4.46; 95% CI 1.24–16.08; p 0.025) was associated with an increased risk. Univariate analysis also demonstrated that hand-sewn anastomosis was associated with significantly higher risk of MU perforation compared with linear stapling (OR 4.25, 95% CI 1.70-10.69; p = 0.002). Conclusion Although most MUs respond to medical therapy, nearly one-quarter of patients require endoscopic or surgical intervention. Resumption of smoking after surgery and male sex are independently associated with perforation. These findings support early recognition of refractory disease, risk-factor modification, and timely escalation of care.

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