Efficacy of Endoscopic Hydrostatic Balloon Dilation as Initial Intervention for Dysphagia/Emesis After Vertical Sleeve Gastrectomy

Abstract

Introduction: Vertical sleeve gastrectomy (VSG) has gained popularity worldwide and is now the most commonly performed bariatric surgery in the USA. Dysphagia with emesis is commonly encountered after VSG, and a potential cause for these symptoms is partial obstruction of the gastric sleeve. Suggested treatment strategies to manage post-operative gastric stenosis include conservative medical therapy, endoscopic intervention, and surgical revision to gastric bypass surgery. The aim of this study is to determine the prevalence of partial obstruction of the sleeve gastrectomy in patients after VSG and to assess the efficacy of endoscopic hydrostatic balloon dilation as an intervention.Figure 1Figure 2Methods: This is a retrospective chart review of 400 consecutive patients above 18 years of age who underwent sleeve gastrectomy at a large, urban community hospital between 2013 and 2015. Patients with previous bariatric procedures were excluded. Patients with dysphagia and/or vomiting were offered upper endoscopy. Partial obstruction of gastric sleeve due to narrowing was defined by: 1. inability to pass a 9.6mm endoscope; 2. narrowing seen in upper GI x-ray series; or 3. sharp angulation of the gastric sleeve hindering passage of a 9.6 mm endoscope. Results: Out of 353 patients included in the final analysis, 33 (9.3%) had partial obstruction of gastric sleeve. Twenty-five patients (7.1%) had sharp angulation of the gastric sleeve and 8 (2.3%) had frank stenosis of the gastric sleeve. All 33 patients underwent endoscopic hydrostatic balloon dilation as the initial intervention. 13 (39%) had resolution of their symptoms with a single dilation, 5 (15%) required two sessions of dilation, 5 (15%) required three sessions of balloon dilation and 8 (24%) obtained only partial symptom resolution with multiple balloon dilations. Two (6%) patients showed no improvement with balloon dilation. Conclusion: Gastroenterologists will be more often asked to evaluate patients with dysphagia VSG. Dysphagia due to partial obstruction of the gastric sleeve is common in these patients and our present findings are consistent with prior small studies of gastric sleeve stenosis. There are no current guidelines on the management of symptomatic obstruction of the gastric sleeve after VSG. Our results suggest that an initial endoscopic balloon dilation of the gastric sleeve improve symptoms of dysphagia and vomiting in ˜70% of the patients. Up to 30% of the patients may require multiple dilation sessions before resolution of symptoms.