Usage of Triamcinolone in Treating Gastro-Jejunal Anastomotic Stenosis: A Case Report

Abstract

Purpose: More than one-third of the adults and almost 17% of the youth in U.S. are obese. Obesity is one of the biggest threats health care system is facing today. Bariatric surgery is an effective surgical option in patients with morbid obesity (body mass index (BMI) > 40 kg/m2) for weight reduction. Rouxen-Y-Gastric Bypass (RYGB) is the most common bariatric surgery performed these days. Stenosis of Gastro-Jejunal Anastomosis (GJA) is one of the most common long term complications of RYGB. It occurs in approximately 3-12% of patients. Endoscopic dilation of the GJA stenosis with a balloon or bougie is considered the treatment of choice. We present a case of severe GJA stenosis post RYGB, which was treated by intra-lesional injection of Triamcinolone in addition to balloon dilation, which gave excellent results. A 33 year old white male with BMI of 55 kg/m2, underwent a laparoscopic RYGB. Five weeks after surgery, he was referred to our Gastroenterology clinic for dysphagia. Esophagogastroduodenoscopy (EGD) showed severe stenosis of GJA stoma. It was dilated with a Pyloric Balloon Dilator (PBD) up to 8 mm. Repeat EGD in one week showed persistent GJA stenosis, which was again dilated to a maximum of 8 mm. During the third EGD session, the GJA stoma still had significant stenosis. It was then injected with 5 ml of triamcinolone (10 mg/mL) and is dilated to a maximum of 10 mm sequentially with a PBD. EGD after one week showed preserved dilation of GJA stoma. It was then sequentially dilated with a PBD to 12 mm during the same session and then to 15 mm during the next EGD session within a week. EGD after 4 weeks showed GJA stoma with no stenosis, with patient being asymptomatic. GJA stenosis can be due to inflammation and fibrosis of the stoma, poor surgical technique and marginal ulcers of the stoma. Common symptoms are dysphagia, nausea and vomiting. Most cases of GJA stenosis can be treated with one to two endoscopic balloon dilations. Severe cases may require three to five dilations. Stenoses refractory to dilation are usually treated with revision surgery. Intralesional steroid injections have shown benefit in treating refractory benign esophageal strictures, by decreasing the number of dilation sessions required, increasing the dilation diameter and symptom free period. They act by inhibiting matrix protein genes, thereby preventing fibrosis and formation of scar tissue. Our case demonstrates the effective usage of intralesional steroid injection for recurrent and persistent GJA stenosis, thereby decreasing the number of repeat EGD dilations required and potentially preventing arduous revision surgery.