title: Revision using totally hand-sewn gastrojejunostomy and truncal vagotomy for refractory marginal ulcer after laparoscopic Roux-en-y gastric bypass: a case series.
abstract: BACKGROUND
  Marginal ulcer (MU) is not infrequent after laparoscopic Roux-en-Y gastric bypass (LRYGB). Medication plus lifestyle modification remains the mainstay solution. Patients with refractory MU may be candidates for revisional surgery.
  
  
  OBJECTIVE
  To summarize our experience of revisional surgery for treating refractory MU after LRYGB.
  
  
  METHODS
  University hospital, Taiwan.
  
  
  METHODS
  A retrospective analysis was performed for 11 patients with refractory MU undergoing totally hand-sewn gastrojejunostomy and truncal vagotomy at our institution between August 2005 and May 2015. The mean follow-up after surgery was 28.0±16.2 months (range, 10-48 mo); 9 patients (81.8%) were followed up more than 1 year after.
  
  
  RESULTS
  The mean age of the cohort (7 males; 4 females) was 39.5±16.0 years (range, 19-66 yr), with a mean initial body mass index of 37.5±9.3 kg/m2(range, 32.1-57 kg/m2). Intractability was the dominant manifestation (100%); 8 patients (72%) had stricture at the gastrojejunostomy. The mean interval from initial LRYGB to refractory MU and revisional surgery was 10.2±7.7 months (range, 4-28 mo) and 38.7±21.6 months (range, 10-67 mo), respectively. The average operation time was 150.4±59.8 minutes (range, 80-300 min), and the average length of hospital stay was 4.2±1.4 days (range, 2-7 d). The 9 patients with more than 1 year follow-up all achieved endoscopic resolution of the refractory MU.
  
  
  CONCLUSIONS
  Although longer follow-up is warranted, revisional surgery with totally hand-sewn gastrojejunostomy and truncal vagotomy can be an effective solution for refractory MU.
authors.affiliation: Bariatric and Metabolic International Surgery Center, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan; Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan; Weight Management Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan; Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan. Electronic address: dr.changpochih@hotmail.com.
authors.forename: Po-Chih
authors.initials: PC
authors.lastname: Chang
authors.affiliation: Body Science and Metabolic Disorders International Medical Center, China Medical University Hospital, Taichung 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; Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan.
authors.forename: Chi-Ming
authors.initials: CM
authors.lastname: Tai
authors.affiliation: Bariatric and Metabolic International Surgery Center, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan; Weight Management Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan.
authors.forename: Ivy Ya-Wei
authors.initials: IY
authors.lastname: Huang
authors.affiliation: Body Science and Metabolic Disorders International Medical Center, China Medical University Hospital, Taichung City, Taiwan.
authors.forename: Ming-Che
authors.initials: MC
authors.lastname: Hsin
authors.affiliation: Division of General Surgery, Department of Surgery, E-Da Cancer Hospital, I-Shou University, Kaohsiung City, Taiwan.
authors.forename: Chao-Ming
authors.initials: CM
authors.lastname: Hung
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D015994:Incidence; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D061646:Operative Time; D010437:Peptic Ulcer / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D013536:Suture Techniques; D013624:Taiwan / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D015167:Vagotomy, Truncal / Q000379:methods*; D055815:Young Adult
keywords: Laparoscopic Roux-en-Y gastric bypass; Marginal ulcer; Revisional surgery; Total hand-sewn gastrojejunostomy; Truncal vagotomy