Prophylactic PPI Use
It has now become a routine by surgeons to prescribe PPI routinely following RYGB. The same was also shown by an international survey where 88 % of surgeons routinely preferred prophylactic PPI usage [37]. But whether this usage really impacts the outcome of MU and when used, the exact duration of usage has not been outlined.
In literature, the duration of postoperative PPI usage has been reported to be between 30 days to 2 years, a few have suggested lifelong usage too. But with the understanding that the gastric acidity has a big role in the pathophysiology of MU, PPIs continue to be widely used. Gumbs et al. had the rate of MU falling to zero with prophylactic PPI therapy compared to no PPI therapy, but the sample size was small [46]. A recent report also showed that prophylactic PPI usage had an impact in preventing MU [47]. D’Hondt et al. found no statistical difference in the incidence of MU with/without PPI prophylaxis in patients without H.pylori infection [42]. But what was interesting to note was that in pre-operatively H.pylori positive patients with eradication, PPI had a beneficial effect in protecting against MU. They hypothesised that pre-operative H.pylori infection could lead to gastritis leading to increased ulcer risk, which was reduced by PPI usage. Currently no Level 1 evidence exist on the actual impact of this usage.
Also based on the understanding of pathophysiology, it is also now clear that the first 12 months is when most MU’s are seen. Hence it is more logical to continue PPI therapy for atleast for 1 year. The risks of continuing PPI for longer periods needs special consideration. Carr RJ has recently analyzed the existing literature to propose a management algorithm for MU [48]. For prophylaxis PPIs were recommended for 6-12 months along with risk factor modification for low risk patients with longer duration to be considered for higher risk patients e.g. patients with NSAID usage, smoking etc. Long term PPI therapy can cause calcium malabsorption with increasing risk of osteoporosis and hip fracture, iron and B12 deficiency and hence is to be used with caution [49-51].
