Anastomotic (marginal) ulcers appear in 16% of patients post-bariatric surgery¹. Patients commonly present with abdominal pain, dyspepsia, nausea and even bleeding². Standard treatment is high-dose PPIs (with or without sucralfate) with endoscopic surveillance, yet some patients experience refractory chronic ulcers (>12 months), which require surgical resection and anastomotic revision³. PuraStat, a transparent synthetic peptide gel, supports haemostasis and mucosal repair of ulcers by forming a nanofibre scaffold upon contact with bodily fluid⁴. A previous case series demonstrated success in anastomotic ulcer healing², and an observational study showed efficacy in gastrointestinal bleeding management⁴. Light brushing of the ulcer surface can induce capillary bleeding, theoretically enhancing PuraStat’s efficacy, but this technique has not been explored in current literature. This single-centre case series of patients who had anastomotic ulcer brushing followed by PuraStat application during endoscopy aims to describe efficacy of this technique in terms of symptom resolution, endoscopic evidence of healing and need for follow-up endoscopy.

Fourteen adults with anastomotic ulceration post-gastric bypass surgery, who underwent endoscopy with ulcer brushing followed by either 3mL or 5mL PuraStat application at Homerton University Hospital between 2018 and 2025, were included. Data retrospectively collected from patients’ electronic records included demographics, smoking status, bariatric history, presenting symptoms, diagnoses of chronic ulceration, complications (gastrointestinal bleeding or perforation), and concurrent medical therapy (PPIs and sucralfate). Outcomes were recorded as documented symptomatic improvement, evidence of healing on subsequent endoscopy, and discharge from endoscopic surveillance.

All patients received high-dose PPI therapy, with the majority also receiving sucralfate. Most patients (10/14, 71.4%) demonstrated both symptomatic and endoscopic improvement. Of the two patients without endoscopic healing, one had symptom resolution and did not need further OGDs, while the other had stent insertion for stricturing, with revision surgery planned. Of two patients with ongoing symptoms, one is currently awaiting clinic follow-up to check for symptom resolution after a recent OGD, and one underwent six OGDs due to refractory symptoms related to a gastric intra-thoracic remnant. Other patients requiring four to six PuraStat-assisted OGDs (7/14, 50%) had persistent symptoms, with two awaiting revision surgery, or were smokers (3/7, 42.9%). There were no complications observed.

Endoscopic PuraStat application after ulcer brushing was well-tolerated and had favourable clinical and endoscopic outcomes. Prolonged follow-up occurred in smokers and those with complex postoperative anatomy, but even slowly progressing patients showed endoscopic evidence of ulcer healing. No major complications were observed, supporting the safety of repeated applications. However, this study lacked a control arm, limiting comparison with standard therapy as exact PPI and sucralfate regimes varied between patients, and limiting investigation into the efficacy of ulcer brushing versus using PuraStat alone. Overall, PuraStat with ulcer brushing is a promising option for anastomotic ulcers, but prospective comparative studies are needed to cement the efficacy and safety of this technique.