Advertisement

Surgical Endoscopy

, Volume 22, Issue 8, pp 1746–1750 | Cite as

Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass

  • Andrew Ukleja
  • Bianca B. Afonso
  • Ronnie Pimentel
  • Samuel Szomstein
  • Raul Rosenthal
Review

Abstract

Objective

Stricture formation at the gastrojejunal anastomosis is a relatively common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to report the incidence of stomal strictures after LRYGB in our institution and report our experience with their management by endoscopic balloon dilatation.

Methods

This is a retrospective study of 1012 patients who underwent LRYGB from January 2001 to May 2004. Patients with nausea and vomiting after the surgery, suspected of having gastrojejunal (GJ) anastomotic stricture, had upper endoscopy. Stomas less than 10 mm in diameter, or those not allowing passage of the scope were considered significant strictures and were treated with balloon dilations. Dilations were performed with a through-the-scope (TTS) balloon, with sizes ranging from 6 to 18 mm. The following data were collected from these patients: age, sex, body mass index (BMI), comorbidities, size of balloon catheter, time from surgery until symptoms onset, number of endoscopies needed to relief symptoms, and complications of the procedure.

Results

Sixty-one patients (46 females and 15 males) were found to have anastomotic strictures, corresponding to an incidence of 6%. In total, 134 upper endoscopies were performed, with 128 dilatations. The average age was 41.7 years (range: 19–68 years); mean preoperative BMI was 45 kg/m2 (range: 42–61 kg/m2). Mean time from surgery to symptoms onset was 2 months (range: 1–6 months). The number of dilations per patient was as follows: a single dilation in 28% of patients, two dilations in 33%, three dilations in 26%, four dilations in 11.5%, and five dilations in 1.5% of patients. All the patients responded to dilation without need for formal surgical revision. However, after balloon dilatation three patients (4.9%), all females, had bowel perforation by radiological criteria (free air on X-ray), which corresponded to 2.2% of all dilatations. The maximum balloon size used in this group was 13.5 mm. All three patients had exploratory laparoscopy without finding of perforation site. They were treated with bowel rest, intravenous antibiotics for 7 days, and drain placement. No factors were identified to predict a risk of perforation.

Conclusion

This is the largest study to evaluate the outcome of endoscopic dilatations of GJ strictures after RYGB. Endoscopic balloon dilation is a safe and effective treatment for anastomotic strictures. However, it carries a small risk of perforation. Further case studies are needed to determine risk factors for perforation and if the patients can be managed conservatively in this setting.

Keywords

Bariatric Surgical–Technical G-I endoscopy Endoscopy 

References

  1. 1.
    National Institutes of Health Conference (1995) Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. Executive summaryGoogle Scholar
  2. 2.
    Schauer PR, Ikramuddin S (2001) Laparoscopic surgery for morbid obesity. Surg Clin North Am 81:1145–1179PubMedCrossRefGoogle Scholar
  3. 3.
    Blachar A, Federle MP, Pealer KM, Ikramuddin S, Schauer PR (2002) Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings. Radiology 223:625–632PubMedCrossRefGoogle Scholar
  4. 4.
    Wittgrove AC, Clark GW (2000) Laparoscopic gastric bypass, Roux-en-Y-500 patients: technique and results, with 3–60 months follow-up. Obes Surg 10: 233–239PubMedCrossRefGoogle Scholar
  5. 5.
    Schauer P, Ikramuddin S et al (2000) Outcomes After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity. Ann Surg 232(4):515–529PubMedCrossRefGoogle Scholar
  6. 6.
    Wittgrove AC, Clark GW, Tremblay LJ (1994) Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 4:353–357PubMedCrossRefGoogle Scholar
  7. 7.
    Ukleja A, Stone RL (2004) Medical and gastroenterologic management of the post-bariatric surgery Patient. J Clin Gastroenterol 38(4):312–320PubMedCrossRefGoogle Scholar
  8. 8.
    Gonzalez R, Lin E et al (2003) Gastrojejunostomy during laparoscopic gastric bypass—analysis of 3 techniques. Arch Surg 138:181–184PubMedCrossRefGoogle Scholar
  9. 9.
    Higa K, Boone K, Ho T (2000) Complications of the laparoscopic Roux-en-Y gastric bypass: 1040 patients—what have we learned? Obes Surg 10:509–513PubMedCrossRefGoogle Scholar
  10. 10.
    Nguyen NT, Goldman C, Rosenquist JC et al (2001) Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality-of-life, and costs. Ann Surg 234:279–291PubMedCrossRefGoogle Scholar
  11. 11.
    Dresel A, Kuhn JA, Westmoreland MV et al (2002) Establishing a laparoscopic gastric bypass program. Am J Surg 184:617–620PubMedCrossRefGoogle Scholar
  12. 12.
    De Maria EJ, Sugerman HJ, Kellum JM et al (2002) Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg 235:640–647CrossRefGoogle Scholar
  13. 13.
    Papasavas PK, Hayetian FD, Caushaj PF et al (2002) Outcome analysis of laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 16:1653–1657PubMedCrossRefGoogle Scholar
  14. 14.
    Papasavas PK, Caushaj PF, McCormick JT et al (2003) Laparoscopic management of complications following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 17:610–614PubMedCrossRefGoogle Scholar
  15. 15.
    Abdel-Galil E, Sabry AA (2002) Laparoscopic Roux-en-Y gastric bypass—evaluation of three different techniques. Obes Surg 12:639–642PubMedCrossRefGoogle Scholar
  16. 16.
    Gould JC, Needleman BJ, Ellison EC et al (2002) Evolution of minimally invasive bariatric surgery. Surgery 132:565–572PubMedCrossRefGoogle Scholar
  17. 17.
    Oliak D, Ballantyne GH, Davies RJ et al (2002) Short-term results of laparoscopic gastric bypass in patients with BMI ≥ 60. Obes Surg 12:643–647PubMedCrossRefGoogle Scholar
  18. 18.
    Matthews BD, Sing RF, DeLegge MH et al (2000) Initial results with a stapled gastrojejunostomy for the laparoscopic isolated Roux-en-Y gastric bypass. Am J Surg 179:476–481PubMedCrossRefGoogle Scholar
  19. 19.
    Rossi TR, Dynda DI, Estes NC, Marshall S (2005) Stricture dilation after laparoscopic Roux-en-Y gastric bypass. Am J Surg 189:357–360PubMedCrossRefGoogle Scholar
  20. 20.
    Ahmad J et al (2003) Endoscopic ballon dilation of gastroenteric anastomotic stricture after laparoscopic gastric bypass. Endoscopy 35:725–728PubMedCrossRefGoogle Scholar
  21. 21.
    Go MR, Muscarella P et al (2004) Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass. Surg Endosc 18:56–59PubMedCrossRefGoogle Scholar
  22. 22.
    Barba CA, Butensky MS et al (2003) Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass. Surg Endosc 17:416–420PubMedCrossRefGoogle Scholar
  23. 23.
    Schwartz ML, Drew RL et al (2004) Stenosis of the gastroenterostomy after laparoscopic gastric bypass. Obes Surg 14:484–491PubMedCrossRefGoogle Scholar
  24. 24.
    McCarty TM, Arnold DT et al (2005) Optimizing outcomes in bariatric surgery—outpatient laparoscopic gastric bypass. Ann Surg 242:494–501PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Andrew Ukleja
    • 1
  • Bianca B. Afonso
    • 2
  • Ronnie Pimentel
    • 1
  • Samuel Szomstein
    • 3
  • Raul Rosenthal
    • 3
  1. 1.Department of GastroenterologyCleveland ClinicWestonUSA
  2. 2.Department of Internal MedicineCleveland ClinicWestonUSA
  3. 3.Department of Minimally Invasive SurgeryCleveland ClinicWestonUSA

Personalised recommendations