Just curious where most of you are getting your advice on using NSAID's post-op?  Oddly enough my doc put me on Meloxicam immediately post op... it's an NSAID anti-inflammatory.  The only "don't take NSAID" advice was, was to not double-dip by taking ibuprofen while taking meloxicam.

 From my surgeon.

From anyone who knows anything RNY post-op.

Don't take NSAIDS!!

i would challenge your doc, seriously.  is he a bariatric surgeon or just a general surgeon??

No NSAIDS!! says my bariatric surgeon.

NSAIDs and Ulcers After RNY

Articles on NSAIDs and ulcers after RNY surgery which demonstrate why Duodenal Switch is preferred for patients requiring non steroidal anti-inflammatory drugs post-op.

 

 

Perforated marginal ulcers after laparoscopic gastric bypass.
Felix et al. Oct 2008
PubMed Abstract

BACKGROUND: Perforated marginal ulcer (PMU) after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a serious complication, but its incidence and etiology have rarely been investigated. Therefore, a retrospective review of all patients undergoing LRYGB at the authors' center was conducted to determine the incidence of PMU and whether any causative factors were present.

METHODS: A prospectively kept database of all patients at the authors' bariatric center was retrospectively reviewed. The complete records of patients with a PMU were examined individually for accuracy and analyzed for treatment, outcome, and possible underlying causes of the marginal perforation.

RESULTS: Between April 1999 and August 2007, 1% of the patients (35/3,430) undergoing laparoscopic gastric bypass experienced one or more perforated marginal ulcers 3 to 70 months (median, 18 months) after LRYGB. The patients with and without perforation were not significantly different in terms of mean age (37 vs 41 years), weight (286 vs 287 lb), body mass index (BMI) (46 vs 47), or female gender (89% vs 83%). Of the patients with perforations, 2 (6%) were taking steroids, 10 (29%) were receiving nonsteroidal antiinflammatory drugs (NSAIDs) at the time of the perforation, 18 (51%) were actively smoking, and 6 of the smokers also were taking NSAIDs. Eleven of the patients (31%) who perforated did not have at least one of these possible risk factors, but 4 (36%) of the 11 patients in this group had been treated after bypass for a marginal ulcer. Only 7 (20%) of the 35 patients who had laparoscopic bypass, or 7 (0.2%) in the entire group of 3,430 patients, perforated without any warning. There were no deaths, but three patients reperforated.

CONCLUSIONS: The incidence of a marginal ulcer perforating after LRYGB was significant (>1%) and appeared to be related to smoking or the use of NSAIDs or steroids. Because only 0.2% of all patients acutely perforated without some risk factor or warning, long-term ulcer prophylaxis or treatment may be necessary for only a select group of high-risk patients.

 

Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn?
Sasse et al. May 2008
PubMed Abstract

BACKGROUND: Patients undergoing Roux-en-Y gastric bypass for the resolution of morbid obesity have significant medical sequelae related to their weight. One of the most common comorbid conditions is joint pain requiring the use of non-steroidal anti-inflammatory medications (NSAIDs). In addition to NSAIDs, patients may engage in behaviors such as smoking and alcohol misuse that increase the risk of long-term postoperative complications to include gastric perforation.

METHODS: Data on 1,690 patients undergoing gastric bypass surgery were collected prospectively and reviewed retrospectively.

RESULTS: We identified seven patients who presented to an emergency room and subsequently required emergent surgical intervention for repair of gastric perforation. Six of the seven cases involved use or abuse of NSAIDs.

CONCLUSION: Important characteristics were identified including the use of NSAIDs, alcohol use, and non-compliance with routine long-term postoperative follow-up. Identifying those patients at high risk may decrease the incidence of this potentially life-threatening complication.

 

Predictors of endoscopic findings after Roux-en-Y gastric bypass.
Wilson et al. Oct 2006
PubMed Abstract

OBJECTIVES: To evaluate predictors of endoscopic findings in symptomatic patients after Roux-en-Y gastric bypass (RYGBP) for obesity.

METHODS: A retrospective chart review of 1,001 RYGBP procedures was performed. Two hundred twenty-six (23%) patients were identified as having endoscopy to evaluate upper gastrointestinal symptoms following surgery. Polychotomous logistic regression analysis was used to assess predictors of normal endoscopy, marginal ulcers, stomal stenosis, and staple-line dehiscence.

RESULTS: The most common endoscopic findings were 99 (44%) normal postsurgical anatomy, 81 (36%) marginal ulcer, 29 (13%) stomal stenosis, and 8 (4%) staple-line dehiscence. Factors that significantly increase the risk of marginal ulcers following surgery include smoking (AOR = 30.6, 95% CI 6.4-146) and NSAID use (AOR = 11.5, 95% CI 4.8-28). PPI therapy following surgery was protective against marginal ulcers (AOR = 0.33, 95% CI 0.11-0.97). Median time for diagnosis of marginal ulcers following surgery was 2 months, and 77 of 81 (95%) presented within 12 months.

CONCLUSIONS: Following RYGBP surgery for obesity, smoking and NSAID use significantly increase the risk of marginal ulceration, and PPI therapy is protective. Because a significant majority of marginal ulcers present within 12 months of surgery, it may be reasonable to consider prophylactic PPI therapy during this time period, especially for high risk patients.

 

Spectrum of endoscopic findings and therapy in patients with upper gastrointestinal symptoms after laparoscopic bariatric surgery.
Yang et al. Sept 2006
PubMed Abstract

BACKGROUND: More should be known about the spectrum of endoscopic abnormalities and treatments in patients with upper gastrointestinal (UGI) symptoms after laparoscopic bariatric surgery.

METHODS: Patients referred for endoscopic evaluation of UGI symptoms after laparoscopic bariatric surgery were studied. Clinical manifestations, endoscopic findings and therapy were recorded and correlated.

RESULTS: 76 patients who had undergone laparoscopic vertical banded gastroplasty (LVBG) and 28 who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGBP) underwent 160 instances of upper endoscopy. The symptoms included nausea or vomiting (n=47, 29.4%), epigastric discomfort (n=44, 27.5%), UGI bleeding (n=26, 16.3%), heartburn or acid regurgitation (n=26, 16.3%), dysphagia (n=10, 6.3%) and anemia with dizziness (n=7, 4.4%). The endoscopic diagnosis consisted of normal findings (n=57, 35.6%), marginal ulcer (n=39, 24.4%), erosive esophagitis or esophageal ulcer (n=21, 13.1%), food impaction (n=21, 13.1%), stenosis or stricture (n=14, 8.8%), gastric ulcer (n=7, 4.4%), and duodenal ulcer (n=1, 0.6%). Patients with UGI bleeding, dysphagia and LRYGBP tended to have endoscopic abnormalities (P

Mexicam from which doc--PCP or surgeon? And for what type of pain?  PCP may not always realize NSAID issues.  My surgoeon has recommended Celebrex to a select few pateints, to be taken 20-30 minutes after Prilosec to coat the pouch.  The few select patients were those with pain prior to surgery and the wt loss had minimumal results on their pain.  Votaren is a topical ointment that works as an inflammatory and only 5% of the NSAID gets into your bloodstream.  My wife had a revision in 2008, and she had immense back pain issues before the revision. My surgeon gave my wife Meloxican for her chronic back pain and she used it for a couple of years, before her pain managment doc put her on Voltaren. DAVE

 The meloxicam was sent home with me, per my surgeons orders on the day of discharge.  The script was actually written by the PA though...  The post-op paperwork from the hospital mentions not taking other NSAID's while on Meloxicam.

This is from my bariatric surgeon, who is a surgeon at a center of excellence, at the biggest hospital in Seattle, WA.

 I was almost sent home with NSAIDS from the hospital too.  But I questioned it and it turned out to be a pharmacy mistake.

I've always thought some people were more susceptible to ulcers than others and I still think that. I know of lots of folks who take NSAIDs. So, my doc was ok with me occasionally taking Midol or ibuprofen so I did (less than once a month). Guess who wound up with a baby ulcer? me. I'm not doing it anymore. Pain in the butt but I'm lucky we caught it early

I think most of us got that advice from our bariatric surgeons.

Have you discussed the use of NSAIDS with your surgeon?  Do you feel comfortable taking them?

My doc said no NSAIDS. My primary told me to take some for a sprained ankle. I told him I couldn't, I had RNY. He asked why not? I told him they could cause ulcers in the remnant stomach. He said, well I learn something new everyday! So it's always good to challenge your doc. They don't know it all.