Alberto Migliorini

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.

Background and Objectives: Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed metabolic and bariatric surgeries worldwide. Marginal ulcers (MU) are a common complication following RYGB, yet their pathophysiology and the contributing risk factors to their development are not fully understood. Materials and Methods: This retrospective cohort study examined patients who underwent RYGB between January 2008 and December 2023, with 1 to 5 years of follow-up. Data collected included patient- and procedure-related risk factors, as well as postoperative MU events. Statistical analysis methods included the independent samples t-tests, multivariate regression, and Cox regression analyses. Results: Our final cohort included 2106 patients and was predominantly female (80.5%), with a mean age of 47.8 ± 12.1 years and body mass index (BMI) of 45.5 ± 7.5 kg/m². MU occurred in 241 (11.4%) patients, with a mean time to occurrence of 4.5 ± 0.02 years. History of smoking (HR = 1.87, p < 0.001) and gastroesophageal reflux disease (HR = 2.36, p < 0.001) significantly increased hazard for MU, while proton pump inhibitor use (HR = 0.18, p < 0.001) was associated with reduced hazard. Aspirin exposure, regardless of dose and chronicity, did not impact MU. Conclusions: Our findings highlight the importance of preoperative assessment and counseling in patients planning to undergo RYGB. Patient-related factors should guide postoperative monitoring and prophylaxis of MU, as this remains a debated topic amongst experts.