What is the management approach for marginal ulcers?

Management of Marginal Ulcers

Initiate high-dose proton pump inhibitor (PPI) therapy for a minimum of 3-6 months combined with immediate elimination of all modifiable risk factors (smoking, NSAIDs, steroids) as first-line treatment for uncomplicated marginal ulcers. 1

Initial Medical Management

• Administer high-dose PPI therapy for 3-6 months minimum as the cornerstone of treatment for all uncomplicated marginal ulcers 1
• Immediately eliminate all modifiable risk factors:
  • Complete smoking cessation 2, 1
  • Discontinue all NSAIDs and steroids 2, 1
  • Address any immunosuppression if present 1

Mandatory Endoscopic Surveillance

• Perform endoscopic surveillance every 3 months until complete ulcer healing is documented and to rule out stenosis development 1
• Obtain biopsy of all ulcers to exclude malignancy - this is strongly recommended in all cases 2, 1

Management of Bleeding Marginal Ulcers

Hemodynamically Stable Patients

• Perform endoscopy first as it can achieve hemostasis and reduce rebleeding, need for surgery, and mortality 1
• Use standard endoscopic techniques for peptic ulcers: injection and mechanical methods preferred over thermal techniques to minimize ischemia risk 2
• Consider angiography with transcatheter angioembolization if endoscopic hemostasis fails or is unavailable 1

Hemodynamically Unstable Patients

• Proceed directly to surgical exploration without delay 2

Management of Perforated Marginal Ulcers

Stable Patients with Perforation <1cm

• Perform laparoscopic primary suture repair with omental patch reinforcement whenever technically possible 2
• This approach is safe and effective even in bariatric surgery patients 2
• Omental patch repair or primary closure is sufficient; revision of gastrojejunostomy is not mandatory 3

Unstable Patients

• Consider damage control surgery and open abdomen approach 2

Critical Intraoperative Assessment

• Always assess for gastro-gastric fistula in the presence of a perforated marginal ulcer following gastric bypass 2
• Explore the gastric remnant to rule out fistula, as this decreases recurrent marginal ulcers 2
• If gastro-gastric fistula is present, 75% of surgical cases will have this finding 4
• Assess all anastomoses after LRYGB, the remnant stomach, and the excluded duodenum 2

Refractory Ulcers (Failed Medical Management)

• If ulcers persist despite 3-6 months of optimal medical therapy:
  • Rule out Zollinger-Ellison syndrome 1
  • Evaluate for structural problems (gastro-gastric fistula, pouch length >5.6cm) 1, 5
  • Consider revisional surgery only after exhausting medical options 1

Surgical Options for Refractory Cases

• Subtotal gastrectomy with revision of gastrojejunal anastomosis is the most common approach 4
• Video-assisted thoracoscopic truncal vagotomy for persistent bleeding 4
• Important caveat: Only 36% of patients achieve symptom resolution, while 57% develop recurrent ulcers after surgical intervention 1
• 25% experience postoperative complications requiring reoperation 4
• 58% have chronic abdominal pain and 33% have intermittent diarrhea at long-term follow-up 4

Antibiotic Management for Perforated Ulcers

• Administer early empiric broad-spectrum antimicrobial therapy targeting Gram-negative bacilli and anaerobes 2
• Short-course therapy (3-4 days IV antibiotics) is effective after adequate source control 2
• Empiric antifungal therapy is NOT supported for perforated marginal ulcers in community-acquired intra-abdominal infections 2
• Adjust antibiotic doses to patient weight and renal function 2

Risk Factors to Address

Modifiable:

• Smoking (OR 2.5) 5
• NSAID use 2, 5
• Steroid use 2

Non-modifiable:

• Diabetes (OR 5.6 on multivariate analysis) 5
• Long gastric pouch length (>5.6cm increases risk) 5

Critical Pitfalls to Avoid

• Do not delay endoscopic surveillance - regular monitoring every 3 months is essential to confirm healing and detect complications like stenosis 1
• Do not proceed to surgery prematurely - given the high recurrence rate (57%) and poor symptom resolution (only 36%), exhaust medical options first 1, 4
• Do not forget to obtain biopsies - malignancy must be excluded in all cases 2, 1
• Do not assume revision surgery is mandatory for perforated marginal ulcers - simple repair with omental patch is sufficient in most cases 3
• Do not overlook gastro-gastric fistula - this is present in 75% of surgical cases and must be ruled out to prevent recurrence 2, 4