title: Revision with Totally Hand-Sewn Gastrojejunostomy and Vagotomy for Refractory Marginal Ulcer after Laparoscopic Roux-en-Y Gastric Bypass.
abstract: BACKGROUND
  Marginal ulcer is not infrequent after laparoscopic Roux-en-Y gastric bypass and could result in undesirable complications, such as intractability, bleeding, or perforation. Those patients who failed medical therapy, regarded as refractory marginal ulcers, may be considered as candidates for revisional surgery. Herein, we make a video presentation of a laparoscopic revisional procedure for refractory marginal ulcer.
  
  
  METHODS
  A 29-year-old morbidly obese woman (initial body mass index 37.1 kg/m(2)), a non-smoker, presented with persistent epigastric pain 3 months after initial laparoscopic Roux-en-Y gastric bypass at another institution. After an exhaustive work-up there, only the gastroendoscopy revealed a marginal ulcer and she underwent medical treatment (proton pump inhibitor and sucralfate) for 3 months, but the patient's symptom aggravated and the serial gastroendoscopies still confirmed the marginal ulcer without obvious resolution after a total of 4 months proton pump inhibitor therapy, suggesting failure of medical treatment and intractability. Laparoscopic revisional procedure with totally hand-sewn gastrojejunostomy and vagotomy was performed to relieve her intractable condition.
  
  
  RESULTS
  The procedure took 130 min, without any intra-operative complications. Blood loss was 80 mL. The patient had an uneventful postoperative course, and the postoperative hospital stay was 3 days. She was relieved of her symptoms after this revisional surgery, and a subsequent gastroendoscopy 15 months later showed no marginal ulcers.
  
  
  CONCLUSIONS
  Though long-term follow-up is needed to draw a definite conclusion, totally hand-sewn gastrojejunostomy and vagotomy remains a practicable revisional procedure to relieve refractory marginal ulcers.
authors.affiliation: Bariatric and Metabolic International Surgery Center, E-Da hospital/I-Shou University, Kaohsiung City, Taiwan. dr.changpochih@hotmail.com.|Division of General Surgery, Department of Surgery, E-Da hospital/I-Shou University, Kaohsiung City, Taiwan. dr.changpochih@hotmail.com.|Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan. dr.changpochih@hotmail.com.|, No. 1, Yi-Da Road, Jiao-Su Village, Yan-Chao Distinct, Kaohsiung City, 824, Taiwan. dr.changpochih@hotmail.com.
authors.forename: Po-Chih
authors.initials: PC
authors.lastname: Chang
authors.affiliation: Bariatric and Metabolic International Surgery Center, E-Da hospital/I-Shou University, Kaohsiung City, Taiwan.|Division of General Surgery, Department of Surgery, E-Da hospital/I-Shou University, Kaohsiung City, Taiwan.
authors.forename: Chih-Kun
authors.initials: CK
authors.lastname: Huang
authors.affiliation: Bariatric and Metabolic International Surgery Center, E-Da hospital/I-Shou University, Kaohsiung City, Taiwan.
authors.forename: Mahendra
authors.initials: M
authors.lastname: Rajan
authors.affiliation: Bariatric and Metabolic International Surgery Center, E-Da hospital/I-Shou University, Kaohsiung City, Taiwan.|Division of General Surgery, Department of Surgery, E-Da hospital/I-Shou University, Kaohsiung City, Taiwan.
authors.forename: Ming-Che
authors.initials: MC
authors.lastname: Hsin
mesh_terms: D000328:Adult; D000897:Anti-Ulcer Agents / Q000627:therapeutic use; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D009765:Obesity / Q000601:surgery*; D010437:Peptic Ulcer / Q000188:drug therapy / Q000209:etiology / Q000601:surgery*; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D012086:Reoperation; D013392:Sucralfate / Q000627:therapeutic use; D014628:Vagotomy
chemical_list: D000897:Anti-Ulcer Agents; D054328:Proton Pump Inhibitors; D013392:Sucralfate
keywords: Laparoscopic Roux-en-Y gastric bypass; Marginal ulcer; Revisional surgery; Total hand-sewn gastrojejunostomy; Vagotomy