Successful resolution of refractory marginal ulcer with celiac artery stenting.

Abstract

Marginal ulcers are a common complication following Roux-en-Y bypass surgeries with an approximate incidence of 4.6%. The pathophysiology is complex and risk factors include smoking, nonsteroidal anti-inflammatory drugs (NSAIDs) use, Helicobacter pylori infection, and a larger pouch size. The management is usually medical encompassing control of modifiable risk factors and the administration of acid-reducing medications with data pointing towards faster healing time by using open capsule proton pump inhibitors (PPIs). Emergent surgical management is indicated for complication such as fistula formation, perforation, stricture, or intractable bleeding. Multiple surgical approaches have been proposed in the past, including: resection of the gastrojejunal (GJ) junction, revision of the bypass and total gastrectomy for recurrent ulcers. We present a unique case of a complicated recurrent marginal ulcer after Roux-en-Y surgery in a patient with multiple surgical revisions that healed completely after placing a celiac artery stent for severe celiac artery stenosis. Our case highlights an association between ischemia and marginal ulcers. This association has been previously theorized, however, there is scarce evidence to support this theory. Our case not only supports this belief but also introduces a novel and potential alternative treatment for resistant marginal ulcers that have failed medical therapy. Our approach hypothesizes that addressing ischemia as the culprit for recurrent marginal ulcers in high-risk populations, might be a minimally invasive, yet successful method for treatment.