Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
Endoscopy. 2011 Nov;43(11):950-4. doi: 10.1055/s-0030-1256951. Epub 2011 Oct 13.
Marginal ulcers are one of the most common complications after gastric bypass. Reported incidence varies widely (0.6-16 %) and pathogenesis is unclear. The aim of the present study was to describe characteristics, risk factors, management, and outcomes of endoscopically documented ulcers.
Data from all patients diagnosed with marginal ulcers at endoscopy between 2003 and 2010 were retrospectively reviewed.
A total of 103 patients with marginal ulcers presented with pain (63 %) and/or bleeding (24 %), a median of 22 months after surgery. Ulcers were located on the anastomosis (50 %) or the jejunum (40 %); sutures were visible in 35 %, and gastrogastric fistulae in 8 %. The mean pouch length was 5.6 cm. Diabetes (odds ratio [OR] 2.5; P = 0.03), smoking (OR 2.5; P = 0.02), and gastric pouch length (OR 1.2; P = 0.02) were significantly associated with marginal ulcer formation on univariate analysis; diabetes was significantly associated on multivariate analysis (OR 5.6; P = 0.003). The risk of developing a marginal ulcer decreased with time (OR 0.8; P < 0.01) and was not associated with the use of nonsteroidal anti-inflammatory drugs. At first endoscopic follow-up, 67 % of ulcers had healed. Recurrence occurred in four patients and nine patients required surgical revision.
The vast majority of marginal ulcers had a favorable outcome after medical treatment. However, 9 % of patients eventually required surgical revision. Therefore, endoscopic follow-up is essential. Diabetes, smoking, and long gastric pouches were significant risk factors for marginal ulcer formation, suggesting increased acid exposure and mucosal ischemia are both involved in marginal ulcer pathogenesis. Management of these factors may prove effective in managing marginal ulcers, and tailoring postoperative proton pump inhibitor therapy to patients with multiple risk factors could be effective.
边缘性溃疡是胃旁路术后最常见的并发症之一。报道的发病率差异很大（0.6-16%），发病机制尚不清楚。本研究旨在描述内镜诊断的溃疡的特征、危险因素、处理和结果。
回顾性分析 2003 年至 2010 年间内镜诊断为边缘性溃疡的所有患者的数据。
共有 103 例边缘性溃疡患者出现疼痛（63%）和/或出血（24%），术后中位数时间为 22 个月。溃疡位于吻合口（50%）或空肠（40%）；35%可见缝线，8%可见胃-肠瘘。胃袋长度平均为 5.6cm。糖尿病（优势比[OR]2.5；P=0.03）、吸烟（OR2.5；P=0.02）和胃袋长度（OR1.2；P=0.02）在单变量分析中与边缘性溃疡形成显著相关；糖尿病在多变量分析中也显著相关（OR5.6；P=0.003）。随着时间的推移，发生边缘性溃疡的风险降低（OR0.8；P<0.01），与非甾体抗炎药的使用无关。首次内镜随访时，67%的溃疡已愈合。4 例患者复发，9 例患者需要手术修正。
大多数边缘性溃疡经药物治疗后有良好的预后。然而，9%的患者最终需要手术修正。因此，内镜随访至关重要。糖尿病、吸烟和长胃袋是边缘性溃疡形成的显著危险因素，提示酸暴露和黏膜缺血均与边缘性溃疡发病机制有关。管理这些因素可能对治疗边缘性溃疡有效，针对具有多种危险因素的患者调整术后质子泵抑制剂治疗可能有效。
