Endoscopic Stricturotomy and Stent Placement for Refractory Gastrojejunal Anastomotic Stricture in a Patient With Roux-en-Y Gastric Bypass Surgery: A Case Report

Abstract

Introduction: Gastro-jejunal (G-J) anastomotic strictures are a common complication after Roux-en-Y gastric bypass. We present a case of symptomatic refractory post RYGB G-J stricture treated with endoscopic stricturotomy using an ERCP sphincterotome. Case: A 62-year-old female with prior gastroplasty and RYGB conversion developed an intractable stricture. She underwent open revision of her gastrojejunostomy, complicated by an anastomotic leak. She remained well for nearly 5 years and re-presented again with nausea and vomiting. Endoscopy confirmed a tight G-J anastomosis restricting passage of the adult upper endoscope. The stricture underwent serial dilations using hydrostatic balloon every 4 weeks. After 3 CRE balloon dilations to 10mm, the stricture remained stenosed. Following her 3rd visit, hydrostatic dilation with fully covered metal stent placement was discussed with the patient and surgical team. Balloon dilation was performed initially to 14mm, allowing passage of the radial echoendoscope to evaluate thickness of the stricture and muscularis propria. Using a 4.4 Fr sphincterotome, mucosal incisions were made at 3 O'clock and 9 O'clock positions followed by placement of a TTS duodenal stent. The patient's symptoms improved dramatically following the procedure. On repeat endoscopy 4 weeks later, the G-J anastomosis remained patent. Consequently, the stent was removed. The patient remained asymptomatic on follow up. Discussion: Gastro-jejunal (G-J) anastomotic strictures are a common complication after RYGB occurring in 5-10% of post-operative patients. While endoscopic balloon dilations are effective, they are associated with recurrence, restenosis and rarely may need surgical revision of the anastomosis. Our patient had intractable symptoms of nausea and vomiting due to a G-J anastomotic stricture. Prior surgeries with complicated post-operative periods meant that she was not deemed an appropriate surgical candidate. Endoscopic balloon dilation is a safe and effective option in the management of anastomotic stricture following RYGB with a low incidence of perforation rates. However, in our patient, balloon dilation every 4 weeks did not result in any significant improvement in the luminal diameter of her stricture or her symptoms. Eventually, she successfully underwent a stricturotomy with stent placement as described above. Following her stricturotomy, her symptoms improved and she tolerated an oral diet. To our knowledge, this is the first described case of endoscopic stricturotomy using a biliary sphincterotome for refractory G-J anastomotic stricture. Conclusion: In RYGB patients who are not surgical candidates, endoscopic stricturotomy and stent placement may have a role in management of intractable symptomatic G-J strictures.