Preventing Recurrent Gastro-Gastric Stricture as a Complication of Roux-en-Y Gastric Bypass Surgery

Abstract

Purpose: Balloon dilation as a treatment for post-surgical anastomotic strictures is minimally invasive and relatively safe. The benefit of through-the-scope dilators has a reported long-term improvement of 48 to 66%. Placement of a temporary stent is an option that we reported for benign esophageal stricture. This is a patient wtih gastro-gastric anastomotic stricture which was treated by injecting triamcinolone (TRIAM) into the stricture, using a protocol described for esophageal strictures, after multiple balloon dilations provided short term relief. Case: A 40 year old female, 4 years after Roux-en-Y gastric bypass surgery, was transferred following extensive small intestine and right colon resection following a small bowel volvulus with infarction of the entire jejunum, ileum, and right colon. A duodenocolostomy was planned as a bridge to transplantation, but was not feasible due to inflammation. Therefore the distal duodenum was closed primarily; EEA gastrogastrostomy with distal decompressive tube gastrostomy was performed. At 1 month she had nausea and vomiting. At EGD there was a high grade stricture of the gastro-gastric anastomosis. Under fluoroscopy, the anastomosis was dilated with through-the-scope balloon dilators. Five additional dilations provided temporary relief. Due to nausea and vomiting, a seventh EGD at day 50 revealed a residual high grade stricture. During this session, the stricture was dilated with a balloon dilator to 12 mm and then the stricture was injected circumferentially 5 times with 10 mg of TRIAM. Due to the absence of recurrent symptoms she did not require repeat dilation for 3 months; EGD prior to transplantation revealed a patent gastro-gastric anastomosis. At 3 months after small intestinal transplantation, she was clinically doing well. Discussion: This case report demonstrates that injection of TRIAM into an anastomotic stricture following GI surgery improves long term efficacy of dilation. TRIAM is preferable to cortisol, as it is locally active for 4 weeks and is more potent at degradation of collagen fibrils. This novel approach appears to be an effective method for managing an unusual complication of gastric bypass surgery without the risk of perforation due to repetitive endoscopic dilations.