Surgical Options for Refractory Anastomotic Ulcer after Roux-en-Y Gastric Bypass: A Narrative Review of the Literature

Abstract

Background:

Marginal ulcer (MU) is a well-recognized complication following Roux-en-Y gastric bypass (RYGB), with a reported prevalence of 0.6%–16%. While most ulcers respond to medical therapy with proton pump inhibitors and risk factor modification, a subset of patients develop refractory ulcers requiring surgical intervention. Despite this clinical challenge, there remains no consensus on the optimal surgical approach for refractory MU.

Methods:

We performed a narrative review of the literature using PubMed, MEDLINE, and Google Scholar databases from January 2000 to December 2024. Search terms included marginal ulcer, anastomotic ulcer, gastric bypass, refractory ulcer, surgical treatment, vagotomy, and revisional surgery. We focused on studies reporting surgical outcomes for refractory MU after RYGB.

Results:

Current surgical options include (1) gastrojejunostomy revision with or without pouch reduction, (2) truncal vagotomy (laparoscopic or thoracoscopic), (3) subtotal or total gastrectomy with esophagojejunostomy, (4) gastric remnant resection, and (5) RYGB reversal with or without conversion to sleeve gastrectomy. Reported success rates vary from 36% to 100% depending on technique and follow-up duration. Recurrence rates remain concerning, ranging from 15% to 57% at 1 year. Risk factors for recurrence include persistent smoking (HR: 5.03), immunosuppression (HR: 4.60), and Nonsteroidal anti-inflammatory drug (NSAID) use (HR: 3.11). Emerging endoscopic approaches, including suturing and stent deployment, show promise as step-up therapy before surgical revision.

Conclusions:

The management of refractory MU after RYGB remains challenging with no single optimal surgical approach. Treatment should be individualized based on ulcer characteristics, the presence of associated complications (gastrogastric fistula and stricture), and patient risk factors. A stepwise algorithm incorporating endoscopic therapy, gastrojejunostomy revision, and salvage procedures is proposed.