Anastomotic ulcer risk after RYGB rises over time, particularly for smokers

Last Updated: 2018-06-27

By Marilynn Larkin

NEW YORK (Reuters Health) - The incidence of anastomotic ulceration after Roux-en-Y gastric bypass (RYGB) surgery is higher than previously thought and increases over time, especially for tobacco users, researchers say.

Dr. Konstantinos Spaniolas of Stony Brook University in New York and colleagues studied 35,075 patients (mean age, 42.5; 81% women) who underwent an RYGB procedure in New York State from 2005 through 2010.

The overall cumulative incidence of anastomotic ulceration was 3.2% one year post-procedure, 4.7% after two years, 7.9% after five years, and 11.4% at eight years after RYGB, according to the JAMA Surgery report, online June 20.

Adjusted hazard ratios for risk factors at the time of surgery that were significantly associated with anastomotic ulceration included male sex (1.14); Medicaid/Medicare coverage (1.31) or other non-commercial health insurance (1.44); chronic obstructive pulmonary disease (1.22); fluid and electrolyte disorders (1.49); renal failure (1.87); psychosis (1.35); hypertension (1.10); and tobacco use (1.56).

The 5-year incidence of anastomotic ulceration ranged from 5.2% for patients with 0 or one risk factor to 15.9% for those with five or more risk factors.

Tobacco use was significantly associated with a higher cumulative incidence of anastomotic ulceration at all time points examined, according to the authors. "The study suggests that the 8-year incidence . . . is approximately 11.4% and increases to 17.8% for patients with a history of tobacco smoking," Dr. Spaniolas said by email.

The findings "underline that the incidence of (anastomotic ulceration) after RYGB is more common than previously reported and that it progressively increases over time," the authors state. Further, "the long-term effect of tobacco use on this complication is profound."

Dr. Spaniolas told Reuters Health, "The findings can be used to tailor procedure selection for patients with exposure to tobacco, potentially steering them away from gastric bypass and towards other bariatric procedures, or extending ulcer prophylaxis measures lifelong for such individuals who undergo gastric bypass."

"Additionally," he said by email, "it reinforces the possible value of long-term bariatric follow up, specifically in an attempt to identify and aggressively treat (these ulcerations) early in their stage of development."

Dr. Kelvin Higa, a clinical professor of surgery at the UCSF-Fresno Medical Education Program in California, said in an email to Reuters Health, "The elective nature of bariatric/metabolic surgery allows for cessation of cigarette smoking - an established risk for most surgical procedures - prior to surgery."

However, he added, because people may start smoking again, "this becomes a life-long issue, as ulcers can occur sporadically many years after surgery."

"Although many factors that are used in determining which procedure is most appropriate for an individual patient, tobacco use prior to surgery, despite quitting smoking, may make sleeve gastrectomy or one-anastomosis gastric bypass a better choice," he suggested.

"There may be other factors, such as NSAID use and the size and orientation of the gastric pouch, which may play an equal role in the pathogenesis of ulcers," he said.

"Also, this study likely underestimates the true incidence of ulcers," he added, "as this data looked at only hospital-based diagnoses, and most patients can be successfully evaluated and treated in a non-hospital setting."

Dr. Eric Sheu of Brigham and Women's Hospital in Boston told Reuters Health the study "is one of the largest and best designed to date (of) risk factors for anastomotic ulceration development in gastric bypass patients."

Like Dr. Higa, he noted that "sleeve gastrectomy is another highly-effective weight-loss surgery that does not carry an increased risk of developing ulcers."

"Given this study's findings," he said by email, "consideration should be given to a sleeve gastrectomy as a bariatric surgical option in current, and perhaps even former, tobacco users to minimize the risk of ulcer disease."

SOURCE: http://bit.ly/2MuXOxg

JAMA Surg 2018.