[Investigation of marginal ulcer after pancreatoduodenectomy]

Marginal ulcer after pancreatoduodenectomy (PD) is a relatively common complication, but if massive bleeding or ulcer perforation occurs together with the marginal ulcer, this condition may be fatal.

To identify the risk factors and management of marginal ulcer after PD.

In all, 438 patients who underwent PD from 2003 to 2017 were retrospectively reviewed and analyzed. After surgery, all patients were administered a histamine H2 receptor antagonist (H2RA) or a proton pump inhibitor (PPI), which was continued after discharge. Marginal ulcer was diagnosed by endoscopy or surgery. The risk factors for marginal ulcer were then investigated using univariate and multivariate analyses.

After a median follow-up time of 2.7 years, 29 patients (6.6%) developed marginal ulcer. Seventeen patients developed marginal ulcer within 1 year after PD, and 7 patients developed marginal ulcer more than 3 years after PD. All 8 patients who underwent surgery for the treatment of marginal ulcer developed acute peritonitis. Two patients with acute peritonitis died within 1 month after surgery. A multivariate analysis found that discontinuation of PPI treatment was the only independent risk factor for marginal ulcer development (P<0.001). In contrast, sex, age, primary disease, procedure, operation time, volume of blood loss, pancreatic texture, development of postoperative pancreatic fistula, postoperative complications, poor glycemic control after PD, and discontinuation of H2RA therapy after PD were not significantly different between the patient group that developed marginal ulcer and the patient group that did not. Sixteen patients were not treated with antacids at the time of marginal ulcer development. The reason for discontinuation of antacids was the decision of the family physician in 8 cases and the decision of the patient in 3 cases.

Marginal ulcer can still develop a long time after PD, and sometimes, it may be fatal. PPI administration should be continued even after a long time has passed, although this therapy is often discontinued for various reasons. It is therefore important for family physicians and patients to recognize the danger of marginal ulcer after PD.