# 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.

## Key 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.