An Algorithmic Approach to the Management of Gastric Stenosis Following Laparoscopic Sleeve Gastrectomy
- 726 Downloads
Gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. This study aims to describe the safety and efficacy of a predefined step-wise algorithm for endoscopic management of GS post-LSG.
Consecutive patients with symptomatic GS post-LSG, presenting between July 2015 and August 2016, were subjected to a predefined treatment algorithm of serial dilations using achalasia balloons, followed by a fully covered self-expanding metal stent (FCSEMS) if dilations were inadequate. Patients who did not respond or opted out of ongoing endoscopic therapy were offered revision Roux-en-Y gastric bypass (RYGB).
Total of 17 patients underwent a median of 2 (range 1–4) balloon dilations. Twelve patients (70.6%) reported clinical improvement with balloon dilation alone, while 3 (17.6%) required subsequent FCSEMS placement. One patient suffered a tear to the muscularis propria with balloon dilation, which was managed conservatively. Overall, 15 (88.2%) reported clinical improvement with endoscopic management. PAGI-SYM scores revealed that the strongest response to therapy, based on mean reduction of score ± SD, was in the following items: nausea (3 ± 1.9, P < 0.001), heartburn during day (2.8 ± 1.5, P = 0.003), heartburn on lying down (3.4 ± 1.4, P < 0.001), reflux during day (2.8 ± 1.9, P < 0.001), and reflux on lying down (3.0 ± 1.9, P < 0.001). Two (11.8%) patients failed endoscopic therapy and underwent RYGB.
Endoscopic management of GS using the described algorithmic approach is safe and effective post-LSG. Patients with severe stenosis or helical stenosis are likely to require revision RYGB.
KeywordsGastric stenosis Balloon dilation Sleeve gastrectomy Fully covered self-expandable metallic stent
The authors were involved in the writing of the manuscript.
Compliance with Ethical Standards
Conflict of Interest
Manoel Galvao Neto is a consultant for Apollo Endosurgery, consultant and SAB member of GI Dynamics, consultant and SAB member of Fractyl Labs, consultant of GI Windows, consultant and SAB member of Ethicon EndoSurgery.
Mouen A Khashab is a consultant for Boston Scientific and Olympus America.
Vivek Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery.
All other authors have no conflicts of interest to declare.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.
Funding Sources or Institutional or Corporate Affiliations
Initial endoscope being advanced through the gastro-esophageal junction with healed staple line visible to the left leading to the site of stenosis (0:10). Endoscope passed through stenotic segment and into the fourth part of duodenum. Savary Guidewire (Cook Medical, Boomington, Indiana) being introduced through the scope into the fourth part of the duodenum (0:30). Inspecting the deflated achalasia balloon (0:50). Achalasia balloon (Rigiflex™ II Single-Use Achalasia Balloon Dilators, Boston Scientific, Natick, MA, USA) being inserted over the wire, situated with the middle of the balloon across the stenotic segment (1:06). Balloon inflated to 20 psi pneumatic pressure which is maintained for 1 min. There is visible relative tissue ischemia at the site of the stenosis (1:24). Balloon deflated and withdrawn followed by re-inspection of stenosis segment (2:00). (MP4 232,436 kb)
- 12.Chouillard EK, Karaa A, Elkhoury M, et al. Intercontinental Society of Natural Orifice, endoscopic, and laparoscopic surgery (i-NOELS). Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for morbid obesity: case-control study. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2011;7(4):500–5.CrossRefGoogle Scholar
- 14.Rentz AM, Kahrilas P, Stanghellini V, et al. Development and psychometric evaluation of the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) in patients with upper gastrointestinal disorders. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2004;13(10):1737–49.CrossRefGoogle Scholar
- 17.Estimate of Bariatric Surgery Numbers, 2011-2015 [Internet]. American Society for Metabolic and Bariatric Surgery. [cited 2016]. Available from: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers
- 24.Paluszkiewicz R, Kalinowski P, Wróblewski T, et al. Prospective randomized clinical trial of laparoscopic sleeve gastrectomy versus open Roux-en-Y gastric bypass for the management of patients with morbid obesity. Wideochirurgia Inne Tech Maloinwazyjne Videosurgery Miniinvasive Tech. 2012;7(4):225–32.CrossRefGoogle Scholar
- 28.Willingham FF, Buscaglia JM. Endoscopic Management of Gastrointestinal Leaks and Fistulae. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2015;13(10):1714–21.Google Scholar