Remnant Gastrectomy as a Pathophysiology Based Treatment of Marginal Ulcer after Roux-en-Y Gastric Bypass: A Retrospective Clinical Series of 41 Patients.

INTRODUCTION: Marginal ulcer (MU) is a typical complication after gastric bypass with reported frequencies from < 1% to 25%. The first line therapy is almost invariably acid reduction by proton pump inhibitors (PPI). In case of complicated MU, revision of the anastomosis is the most frequent surgical treatment, while surgical acid reduction is addressed only rarely. We present the rationale of treating MU by surgical acid reduction and report the results of 41 cases. MATERIALS AND METHODS: G-cell ablation as a reduction of acid stimulation was achieved by remnant gastrectomy (RG). Only if necessary, pouches were reshaped and anastomoses revised. Results were controlled by fluoroscopy on day 2 after surgery. Postoperative controls were carried out after 6 and 12 weeks, 6 and 12 months and in yearly intervals. RESULTS: From February 2018 to March 2025 37 women and 4 men underwent RG. RG was a stand-alone procedure in 14 patients. Only 16 patients underwent revision of their anastomoses. All patients were alive 90 days after surgery and 38 were available for follow up. The median length of hospital stay was 5 days (2–48). Symptoms (vomiting, pain, food intolerance, weight loss) resolved in all cases. Endoscopic control was performed in only 7 patients, therefore the evidence of non-recurrence was mainly based on clinical symptoms. CONCLUSION: RG is based on the pathophysiology of acid production. The results are promising with tolerable complication rates. We suggest to consider the procedure as treatment for complicated MU. • Vagotomy of the remnant stomach due to pouch creation causes local hypoacidity • Lack of parietal cells causes antral hypoacidity in revisional bypass • Subsequent gastrin stimulation increases pouch acidity and causes MU • RG ablates the excess gastrin stimulation and allows healing of MU