title: Varying marginal ulcer rates in patients undergoing laparoscopic Roux-en-Y gastric bypass for morbid obesity versus gastroesophageal reflux disease: is the acid pocket to blame?
abstract: BACKGROUND
  Nissen fundoplication failure rates are increased in obese patients; however, conversion to laparoscopic Roux-en-Y gastric bypass (LRYGB) can resolve or improve gastroesophageal reflux disease (GERD) symptoms. Acid pockets near the gastroesophageal junction may influence these surgical outcomes. Our objective was to compare the outcomes for patients who underwent LRYGB for morbid obesity (MO) versus GERD.
  
  
  METHODS
  A retrospective review of our institution's bariatric database was completed. Statistical analysis included t test and χ(2) test.
  
  
  RESULTS
  LRYGBs were performed from 2001-2011 for MO and 2009-2010 for GERD. Eighty-three percent of patients in the GERD group had undergone previous antireflux surgery. The median time from initial presentation to LRYGB was significantly shorter in the GERD versus the MO group (105 days versus 241 days; P = .009). There was an increased rate of marginal ulcers in the GERD group compared with the MO group, at 50% versus 4.5%, respectively (P = .001). Stomal stenosis was also increased in the GERD group compared with the MO group, at 8.3% and .7%, respectively (P = .091). There were no in-hospital or 30-day mortalities.
  
  
  CONCLUSIONS
  Patients undergoing LRYGB for GERD had a shorter interval to surgery and an increased rate of marginal ulcers compared with those undergoing LRYGB for MO. Operative time was longest among patients in the GERD group. The acid pocket may explain the increased ulcer rate in the GERD population. Use of a smaller sized pouch may improve this outcome.
authors.affiliation: Minimally Invasive Bariatric and Advanced Laparoscopy Fellowship, Department of Medical Education, Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin.
authors.forename: Megan M
authors.initials: MM
authors.lastname: Gilmore
authors.forename: Kara J
authors.initials: KJ
authors.lastname: Kallies
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Mathiason
authors.forename: Shanu N
authors.initials: SN
authors.lastname: Kothari
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects / Q000379:methods; D015992:Body Mass Index; D015331:Cohort Studies; D016208:Databases, Factual; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods; D015390:Gastric Bypass / Q000009:adverse effects / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D015994:Incidence; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000175:diagnosis / Q000601:surgery*; D010437:Peptic Ulcer / Q000209:etiology* / Q000503:physiopathology; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome
keywords: Acid pocket; Complications; Gastroesophageal reflux disease;; Laparoscopic Roux-en-Y gastric bypass;; Marginal ulcer; Nissen fundoplication