Perforated marginal ulcer after Roux-en-Y gastric bypass: a national analysis of operative approaches, outcomes, and practice variations, 2018–2022

Abstract

Perforated marginal (gastrojejunal) ulcer is an uncommon but life-threatening complication after Roux-en-Y gastric bypass. Evidence is limited to single-center series and one 2022 systematic review of approximately 600 patients; contemporary national International Classification of Diseases, Tenth Revision (ICD-10)-era data are lacking. We queried the National Inpatient Sample (2018–2022) for adults with a perforated gastrojejunal ulcer and a code indicating prior bariatric surgery. Operative approach was classified as laparoscopic patch, open patch, revisional gastrojejunostomy/reversal, or non-operative management. Survey-weighted statistics, negative-binomial (length of stay), gamma (total charges), and logistic (predictors of operative repair) models were estimated with hospital cluster-robust standard errors. The cohort included 1,669 unweighted admissions (8,345 weighted). Operative repair was performed in 28.9% (laparoscopic patch 12.6%, open patch 7.2%, revisional/reversal 9.2%); 71.1% were managed non-operatively. Crude in-hospital mortality was 1.1% overall. Non-operative management rose from 64.1% (2018) to 72.0% (2022), while laparoscopic patch declined from 18.1% to 12.1%. Open patch was associated with longer length of stay than laparoscopic patch [incidence-rate ratio 1.41, 95% confidence interval (CI) 1.13–1.77] and higher complication rates after correction for multiple comparisons of sepsis, acute kidney injury, respiratory failure, and venous thromboembolism. Elective admission strongly predicted operative repair (adjusted odds ratio 2.58, 95% CI 1.74–3.83), elective admissions were concentrated in the revisional group, but the reason for elective admission could not be determined from administrative data. Operative rates declined modestly each year (adjusted odds ratio 0.91, 95% CI 0.84–0.98). Case mix differed between laparoscopic-first and open-first centers. In the largest contemporary national cohort to date, non-operative management dominated and increased during 2018–2022. Among operatively managed patients, laparoscopic patch repair was associated with shorter length of stay and a more favorable complication profile than open repair. Because operative approach was not randomized and patients selected for open repair may have carried greater physiologic severity or technical complexity, these associations support—but do not establish—a laparoscopic-first approach where anatomy and physiology permit. Prospective evidence is needed to refine operative vs. non-operative triage.