S2318 Novel Argon Plasma Coagulation Resurfacing for Management of Recalcitrant Marginal Ulceration

Introduction: Marginal ulcers (MUs) may occur after Roux-en-Y gastric bypass (RYGB) and may be recurring or resistant to medical treatment. Endoscopic repair with sutures or clips may be attempted prior to considering revisional surgery. We hypothesized that adjuvant argon plasma coagulation (APC) resurfacing of the ulcer bed and adjacent mucosa followed by overstitch repair could improve healing rates. Methods: We conducted a retrospective chart review of adult patients with a history of RYGB undergoing APC for recurrent or recalcitrant MUs. Ulcers were recurrent if previously healed and reappeared, or recalcitrant if unresponsive to an intensive 8-week proton pump inhibitor course. Healing was evaluated by follow-up endoscopy or symptom resolution 4 weeks post-procedure. Results: Thirteen patients (11 women 78.6%; median age 46 years, IQR 40–56) with MU were included. Median time since RYGB was 21 months (IQR 11–48). Conventional risk factors were absent: all were negative for Helicobacter pylori, none smoked, and one intermittently used nonsteroidal anti-inflammatory drugs. All ulcers had undergone previous unsuccessful treatments, up to 5 interventions per ulcer, including endoscopic suturing without APC, intensive medical therapy, and surgical staple removal. Median pouch size was 5 cm (IQR 4–7). Forrest class III ulcers were most common (n = 10, 76.9%), followed by class IIa (n = 2, 15.4%) and IIc (n = 1, 7.7%). Ulcer beds were resurfaced using APC (flow: 0.8 L/min in 6 cases, 1.0 L/min in 7 cases; power: 15–35 W), followed by sutured repair in all cases. Two patients experienced transient post-procedural abdominal pain. Complete healing occurred in 7 patients after a single intervention, and in one additional patient after a second session, yielding a total success rate of 61.5%. Healing primarily occurred in ulcers without prior endoscopic manipulation, while all 5 treatment failures involved previously manipulated, deep ulcers. Conclusion: In this pilot study, adjuvant APC resurfacing before sutured repair of MUs appears safe and may enhance ulcer healing, potentially avoiding revisional surgery. The technique was most beneficial in treatment-naïve or minimally manipulated ulcers, highlighting the importance of ulcer chronicity and mucosal integrity. Further studies are warranted to refine patient selection and confirm ideal technical aspects of this new technique.