Anastomotic Marginal Ulceration after Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Background Patients who undergo Roux-en-Y gastric bypass (RYGB) can develop anastomotic marginal ulcers, which can lead to other complications such as stricture, bleeding, or perforation. Objective To examine if patients undergoing conversion of sleeve gastrectomy to RYGB (SG-to-RYGB) were at higher risk of marginal ulceration than a cohort of primary RYGB patients. Setting Cleveland Clinic Health System in the United States Method This retrospective study included patients who underwent primary RYGB or SG-to-RYGB at an academic health system between 2015 and 2023. Follow-up ended in March 2025. The Kaplan-Meier method estimated time to incident marginal ulcer. Results The study included 1,910 patients who underwent primary RYGB and 202 patients who underwent SG-to-RYGB. During the follow-up time of 3.8±2.9 years, 275 primary RYGB patients and 40 SG-to-RYGB patients developed a marginal ulcer. The cumulative incidence of marginal ulcer at 5 years was 16% (95% CI, 14%-18%) in the primary RYGB group and 27% (95% CI, 18%-35%) in the SG-to-RYGB group. The cumulative incidence of marginal ulcers at 8 years was 20% (95% CI, 17%-22%) in the primary RYGB group and 35% (95% CI, 20%-47%) in the SG-to-RYGB group (P=0.01). In the SG-to-RYGB group, the cumulative incidence of marginal ulcer between patients who underwent RYGB primarily for GERD versus for inadequate weight loss following SG was not statistically significant. Conclusion Follow-up data up to 8 years indicate that approximately 20% of patients who undergo primary RYGB and 35% of those who undergo SG-to-RYGB may develop marginal ulceration. Given role of antrum in acid secretion, future clinical trials could potentially test if antrectomy at the time of conversion of SG-to-RYGB has the potential to decrease rate of marginal ulceration.