The Role of Therapeutic Endoscopy for Postoperative Management of Obstructive Symptoms After Hand Assisted Roux-En-Y-Gastric Bypass

Abstract

BACKGROUND Stenosis of the gastrojejunal anastomosis is one of the major complications of Roux-en-Y gastric bypass (RYGB). The incidence of strictures after Hand Assisted Roux-en-Y Gastric Bypass (HALGB) as well as the functional result of their endoscopic management by balloon dilation has not been reported. METHODS We conducted a retrospective review of all patients undergoing HALGB in a single institution, single surgeon setting from June 2001 to June 2003. All patients with symptoms (nausea, emesis) potentially related to the gastroenteric anastomosis were studied with upper endoscopy. Patients with endoscopic evidence of strictures were treated by balloon dilation. All dilations were performed by a dedicated team of gastroenterologists. RESULTS 393 patients underwent HALGB during the study period. A total of 34 endoscopies were performed in 27 patients (23 female and 4 male). Strictures were identified in 13 patients (3.3%). 7 patients had an isolated stricture and 6 patients had the stricture in association with an anastomotic ulcer. Four patients had an anastomotic ulcer without evidence of stricture and 10 patients had a normal finding. The presenting symptoms did not differ between the different groups. A single endoscopic balloon dilation (10-18 mm through the scope CRE balloons) was successful in all patients with isolated strictures. A single dilation session was successful in only 2/6 patients with strictures complicated by ulcers. The remaining four patients required 2-3 dilation sessions each. The mean time after bypass for strictures to become symptomatic was 37 days post-operatively (range 29-57). Patients with isolated ulcers presented significantly later, a mean of 169 days after surgery (p<0.05). The mean time after surgery for a stricture complicated by an ulcer to present was 64 days. (p-value N.S. vs stricture) No complications occurred after endoscopic dilation CONCLUSIONS 1 The incidence of strictures after HALGB is comparable to other surgical approaches for RYGB. 2 Endoscopic dilation is a safe and effective approach. 3 Earlier presentation is associated with isolated stricture formation whereas later presentation is associated with anastomotic ulceration with or without a stricuture. 4 Symptom presentation cannot be used to identify the need for endoscopic intervention