Endoscopic jejunal flap suturing for the treatment of refractory marginal ulcers—a case series

TL;DR

This case series explores the use of endoscopic jejunal flap suturing to treat persistent ulcers after bariatric surgery, showing moderate success and highlighting the need for further research.

Contribution

The study evaluates the implementation and outcomes of jejunal flap suturing for refractory marginal ulcers in a clinical setting.

Findings

Jejunal flap suturing had a 90.9% technical success rate but only 45% clinical success in ulcer healing.

All patients who had one-anastomosis gastric bypass (OAGB) experienced endoscopic failure.

Five of seven Roux-en-Y gastric bypass (RYGB) patients achieved ulcer healing.

Abstract

Gastro-Jejunal anastomotic ulcer is a late complication of bariatric surgery, typically responsive to high-dose proton pump inhibitors (PPI). However, persistent ulcers may require surgery. Endoscopic suturing of a jejunal flap has recently shown promise. This study evaluates its implementation in our practice.

We retrospectively analyzed 11 patients with refractory marginal ulcers (≥ 10mm) unresponsive to at least two months of high-dose PPI. In cases with a narrow anastomosis, a self-expandable metallic stent was added. Clinical success was defined as ulcer healing on endoscopy at 8 weeks, while failure included persistent ulcer, perforation, or need for surgery.

Seven patients had undergone Roux-en-Y gastric bypass (RYGB) and four had one-anastomosis gastric bypass (OAGB). Ulcers were diagnosed on average 33 months post surgery. All patients were H. pylori-negative and denied alcohol/NSAID use; four were active smokers. Patients had been on chronic PPI therapy for an average of 25 months. Jejunal flap suturing was performed in 10 patients, with three also receiving a stent. One patient underwent stent placement alone due to stricture to relief obstructive symptoms. The technical success rate was 90.9%, but clinical success was 45%, with four patients requiring surgery. Notably, all OAGB patients had endoscopic failure, while 5 of 7 RYGB patients had ulcer healing.

Jejunal flap suturing showed moderate success in treating marginal ulcers, with a good safety profile. Larger studies are needed to corroborate these findings, especially in OAGB patients.

Figures