Reply

As noted in our editorial, we agree fully with Dr Maton.¹ We also agree with Dr Howden that management of marginal ulceration after Roux-en-Y gastric bypass is difficult.² Available data suggests little role for sucralfate (eg, excluding sucralfate did not change healing rates).³ Proton pump inhibitor bioavailability is compromised by (1) elimination of food-mediated increase in serum gastrin, which limits parietal cell activation; (2) absence of the reservoir function of the stomach with rapid gastric emptying; and (3) a short time available for the capsule to release and dissolve its granules within a limited absorptive surface. This is coupled with a short plasma PPI half-life.⁴ To maximize PPI bioavailability, we suggested trying several daily administrations of solubilized PPI.⁴ Despite Dr Howden’s concerns, soluble PPIs can be easily and cheaply prepared⁵ and are commercially available (ie, FIRST-Omeprazole Compounding Kits, Cutis Pharma, Wilmington, MA). Prior studies confirmed absorption of micronized omeprazole suspended in bicarbonate is excellent.⁶ Although enteric-coated PPI granules and bicarbonate is an alternative, dissolution and absorption may require more time than available.⁷ The study by Schulman et al³ greatly helped elucidate and define the problem of PPI bioavailability. We proposed an experimental approach, as the solution will not come from more opinions but rather needs experimentally derived data such as measuring PPI blood levels, the pH within the pouch, and healing rates with different therapeutic approaches.⁴ “All genuine progress results from finding new facts.”⁸ Let’s set about obtaining the data.