Gastric Stenosis Research Articles

Hemodynamic benefits of celiac artery release for ruptured right gastric artery aneurysm associated with median arcuate ligament syndrome: a case report

BackgroundIt has been reported that median arcuate ligament syndrome is closely associated with gastric or pancreaticoduodenal artery aneurysms. Hemodynamic state plays an important role in the formation of the aneurysms. These aneurysms are treated with open resection or endovascular exclusion. However, whether revascularization of the celiac artery can prevent the aneurysm formation is unknown. This report indicated a possibility that prophylactic revascularization for celiac artery stenosis resulted in decreased shear stress on the collaterals, which may otherwise be susceptible to new aneurysms.Case presentationThis report describes a 51-year-old man who presented with epigastric pain at our hospital. According to contrast enhanced computed tomography (CT), he was diagnosed with a ruptured right gastric artery aneurysm and celiac artery stenosis caused by the median arcuate ligament (MAL). He had a vascular anomaly of the common hepatic artery arising from the superior mesenteric artery (SMA). His vital signs were stable. We informed him of the situation and he chose open surgery rather than endovascular treatment. Following, we resected the aneurysm and transected the MAL. Intraoperative angiography after transection of the MAL showed the antegrade blood flow to the splenic artery instead of the retrograde flow via the prominent collaterals. Follow-up CT confirmed narrowed collateral vessels between the SMA and the celiac artery without de-novo aneurysms.ConclusionWhile the necessity of celiac artery release could be questioned, the present case supports the hemodynamic benefits of MAL transection in terms of de-novo aneurysm prevention.

Short- and Long-Term Outcomes of Endoscope-Assisted Laparoscopic Wedge Resection for Gastric Submucosal Tumors Adjacent to Esophagogastric Junction

BackgroundLaparoscopic wedge resection (LWR) is used to treat gastric submucosal tumors (SMTs). However, LWR can injure the cardia if tumors are near the esophagogastric junction (EGJ), resulting in gastric stenosis. This study’s purpose was to summarize our experience with endoscope-assisted LWR for gastric SMTs within 3 cm of the EGJ and to verify the procedure’s feasibility and safety. MethodsData from 91 consecutive patients with gastric SMTs within 3 cm of the EGJ who underwent endoscope-assisted LWR at our hospital from 2007 to 2017 were obtained from a prospectively maintained database. The clinicopathological results, perioperative data, and long-term follow-up data were analyzed. ResultsAll patients successfully underwent endoscope-assisted LWR. The mean distance from tumor to EGJ was 2.43±0.80 cm. Eighty-two patients underwent laparoscopic exogastric wedge resection (LEWR) and nine underwent laparoscopic transgastric wedge resection (LTWR). Mean operative time was 112.4±48.8 min; mean blood loss was 36.8±53.5 ml. Mean time to first flatus was 2.04±0.68 days. Mean time to liquid intake was 2.53±0.85 days. Mean postoperative hospital stay was 4.97±1.80 days. Three patients (3.3%) had postoperative complications, all Clavien–Dindo grade I. The mean maximum tumor diameter was 3.00±1.96 cm (range 0.5–10). LTWR was used more often than LEWR for SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ. The mean follow-up time was 36.86±29.73 months (range 3–126). There was no stenosis of EGJ or tumor recurrence. Sixteen patients (17.6%) complained of upper gastrointestinal symptoms during the follow-up, which were all relieved by usage of acid suppressive medications. ConclusionsEndoscope-assisted LWR is safe, feasible, and effective for gastric SMTs near the EGJ. LTWR is preferable to LEWR for gastric SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ.

A406 - Laparoscopic Stricturoplasty for Gastric Sleeve Stenosis

Gastric stenosis in patients who have undergone prior sleeve gastrectomy is a rare complication of sleeve gastrectomy with an incidence of less than one percent. Despite its rarity, it can cause significant morbidity with poor per oral tolerance. Ongoing investigations are exploring endoscopic and surgical therapies for sleeve stenosis, however abundant literature is lacking. While endoscopic therapies may be successful in relieving patient symptoms, there is a subset that will fail endoscopic management. Typically, the next step after endoscopic failure is to offer gastric bypass. Here we present a case of sleeve stenosis successfully treated with laparoscopic gastric stricturoplasty. Gastric stricturoplasty offers a safe, effective, and less technically challenging alternative to gastric bypass.

A Case of an Uncommon Complication After Endoscopic Dilation of a Gastric Sleeve Stricture in an Obese Woman

A Case of an Uncommon Complication After Endoscopic Dilation of a Gastric Sleeve Stricture in an Obese Woman

Not Cancer … but Pyloric Stenosis in a 69-year-old?

Idiopathic hypertrophic pyloric stenosis (IHPS) is most commonly reported in infants with rates ranging from 0.25% to 0.8% of all live births. Adult IHPS is rare and only 200 cases have been reported in the literature. We present a patient in her late-sixties with cachexia and severe malnutrition with a gastric mass visualized on CT that initially was concerning for malignancy and was subsequently diagnosed with IHPS. A 69-year-old woman, with limited healthcare exposure, was admitted to the hospital with weight loss, anorexia, fatigue, severe malnutrition (BMI 13.7), severe anemia, elevated inflammatory markers (CRP >200, ESR 76), and hypotension leading to a traumatic fall. She was an active smoker with a 51 pack-year history and consumed 2 alcoholic drinks daily. She denied history of acid reflux and had no known history of H. pylori. Rheumatologic workup was negative. Given lack of medical history and severe cachexia, CT chest and abdomen were obtained as there was concern for malignancy. A right ovarian cyst and cystic lesion in the head of pancreas was initially reported and were subsequently determined to be benign. Due to her continued inability to tolerate oral intake, EGD was performed which revealed gastric stenosis with pinhole opening at the pylorus and no visible ulcerations. Biopsy revealed reactive gastropathy and foveolar hyperplasia without inflammation. Review of CT did show evidence of hypertrophy around the pyloric sphincter. She was endoscopically dilated and was able to advance her diet with careful monitoring for refeeding syndrome. At her three-month follow-up visit, she was tolerating general diet, was slowly gaining weight, and her anemia had resolved. This case demonstrates an uncommon case of adult-onset IHPS causing severe malnutrition and cachexia. Most cases of hypertrophic pyloric stenosis are diagnosed in early infanthood. Initial management often includes nasogastric tube placement to remove gastric contents. Gastrectomy, pyloromyotomy, and pyloroplasty have been recommended for surgical management with laparoscopic pyloroplasty as the preferred intervention due to its favorable safety profile. Dilation is another acceptable treatment option; however has a high recurrence rate of stenosis.Figure: Computed tomography, coronal view of pyloric stenosis in a 69-year-old female.

Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.

Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric surgery worldwide. Gastric sleeve stenosis is the most common postoperative complication, occurring in up to 3.9% of the cases. Current treatment options include endoscopic treatments, such as dilatations and stent placement as well as surgical revisions such as laparoscopic Roux-en-Y gastric bypass (LRYGB), wedge gastrectomy or seromyotomy. A retrospective analysis of our prospectively collected therapeutical endoscopy database was performed between January 2014 and February 2017. We included all cases of axial deviation or stenosis post LSG, which were treated endoscopically. Patients with concomitant sleeve leaks were excluded. Endoscopic interventions were performed under general anaesthesia and fluoroscopic assistance when needed. Sequential treatment with CRE balloons, achalasia balloons (30-40mm) and fully covered stent placement for refractory cases was performed. A total of 1332 LSG were performed. Overall, 27/1332 patients (2%) developed a gastric stenosis. All patients presented an axial deviation at the incisura angularis and 26% had a concomitant proximal stenosis. Successful endoscopic treatments were performed in 56% (15/27) of patients, 73% of the successful patients underwent a single dilatation procedure. All successful cases had a maximum of 3 interventions. The unsuccessful cases (44%) underwent LRYGB. Mean time between the primary surgery and the diagnosis of the stenosis was 10.3months. Mean follow-up after the endoscopic treatment was 11.5months. A stent migration was the only complication (3.7%) recorded. Endoscopic treatment appears to be effective in 56% of patients with post-LSG stenosis. Only one session of achalasia balloon dilatation is necessary in 73% of successful cases. Pneumatic balloon dilatation seems to be a safe procedure in this patient population. Surgical revision into a LRYGB offers good outcomes in patients that have failed three consecutive endoscopic treatments.

An Algorithmic Approach to the Management of Gastric Stenosis Following Laparoscopic Sleeve Gastrectomy.

Gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. This study aims to describe the safety and efficacy of a predefined step-wise algorithm for endoscopic management of GS post-LSG. Consecutive patients with symptomatic GS post-LSG, presenting between July 2015 and August 2016, were subjected to a predefined treatment algorithm of serial dilations using achalasia balloons, followed by a fully covered self-expanding metal stent (FCSEMS) if dilations were inadequate. Patients who did not respond or opted out of ongoing endoscopic therapy were offered revision Roux-en-Y gastric bypass (RYGB). Total of 17 patients underwent a median of 2 (range 1-4) balloon dilations. Twelve patients (70.6%) reported clinical improvement with balloon dilation alone, while 3 (17.6%) required subsequent FCSEMS placement. One patient suffered a tear to the muscularis propria with balloon dilation, which was managed conservatively. Overall, 15 (88.2%) reported clinical improvement with endoscopic management. PAGI-SYM scores revealed that the strongest response to therapy, based on mean reduction of score±SD, was in the following items: nausea (3±1.9, P<0.001), heartburn during day (2.8±1.5, P=0.003), heartburn on lying down (3.4±1.4, P<0.001), reflux during day (2.8±1.9, P<0.001), and reflux on lying down (3.0±1.9, P<0.001). Two (11.8%) patients failed endoscopic therapy and underwent RYGB. Endoscopic management of GS using the described algorithmic approach is safe and effective post-LSG. Patients with severe stenosis or helical stenosis are likely to require revision RYGB.

1054 Endoscopic Management of an Hourglass Gastric Stricture in the Excluded Stomach After Gastric Bypass

1054 Endoscopic Management of an Hourglass Gastric Stricture in the Excluded Stomach After Gastric Bypass

Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy

BackgroundGastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. ObjectiveDetermine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SettingUniversity hospital, France, public practice. Material and methodsThis study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. ResultsA total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1–245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0–86). Uniform gastric shape was acquired after 30–32 SG procedures. ConclusionRoutine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.

Gastropancreatic ligament: Description, incidence, and involvement during laparoscopic sleeve gastrectomy.

During laparoscopic sleeve gastrectomy (LSG), adhesions between the stomach and the pancreas are sometimes found, forming a "gastropancreatic ligament" (GPL). However, the GPL has only been described once in the literature, in 1985. The objective of this study was to determine the incidence of the GPL during LSG, describe this structure and assess its effect on the surgical technique. All patients undergoing primary LSG in our institution (n = 240) and patients referred for gastric fistula (GF) after primary LSG (n = 18) between January 2015 and December 2015 were included. The primary endpoint was the incidence of a GPL during primary LSG. The secondary endpoints were the postoperative complication rate, the postoperative GF rate, and the presence of this ligament during reoperation for GF. Among the 240 patients, a GPL was visible in 49 cases (20.4%) and was described as thin in 34 of these (69.4%). Twelve postoperative complications (5%) were observed, including seven major (2.9%). The GF rate was 2% (n = 5), not requiring reoperation. The gastric stenosis rate was 0.4% (n = 1). The GPL had been previously sectioned in one of the five patients (20%) with postoperative GF. During the study period, 18 patients were referred for GF and 14 were reoperated. A non-sectioned GPL, not described in the operating report, was observed in four patients (28.5%). A GPL was identified in 20.4% of cases. Identification of a GPL could be important in the context of LSG, as section of the ligament allows tension-free stapling to be performed and can therefore possibly reduce the risk of postoperative complications, particularly GF. Clin. Anat. 30:336-341, 2017. © 2017 Wiley Periodicals, Inc.

Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.

Laparoscopic sleeve gastrectomy (LSG) is becoming an increasingly popular form of bariatric surgery, accounting for more than 50% of these procedures performed in the USA. Given this popularity, more is being understood about the complications associated with LSG, which, though uncommon, include the formation of strictures and stenosis. The purpose of this study is to establish a safe and effective protocol for the treatment of stenosis post-LSG using endoscopic balloon dilatation. This is a prospective review of 26 patients who had undergone LSG in Kuwait, followed by sleeve gastrectomy stenosis (SGS) and were then referred to Amiri Hospital for endoscopic balloon dilatation from October 2008 up to June 2016. A total of 26 patients (four males; 22 females) presented with symptoms of stenosis post-LSG during the study period. The mean age of the patients was 34.6±10.8years. The mean body mass index at the time of surgery was 43±1.6kg/m2. The median interval from the initial LSG surgery was 95days. Nine patients had an early presentation (≤3months from surgery), while 17 presented late (>3months). The patients were followed for a mean duration of 156±20days from the last endoscopic balloon dilatation. A total of 23 (88.5%) patients had complete resolution of their symptoms. Adverse events were observed in one patients, who was removed from the study. Gastric stenosis is a rare but potentially serious complication of LSG. Serial dilatation of SGS employing endoscopic balloons is a safe method of treatment, with high efficacy rates. This new method may offer a less invasive alternative to surgical revision. However, if endoscopic treatment fails, surgery is necessary.

Risk factors and management for gastric stenosis after endoscopic submucosal dissection for gastric epithelial neoplasm.

Only a few studies have reported treatment options for stenosis after endoscopic submucosal dissection (ESD) for gastric neoplasms. This study aimed to identify the risk factors for and evaluate the management of stenosis after ESD for gastric epithelial neoplasms in the cardia and antrum. We retrospectively reviewed 1218 patients (1447 gastric epithelial neoplasms) who underwent ESD at Tonan Hospital from June 2004 to November 2015. Post-ESD stenosis was defined when a standard endoscope could not be passed through the site. Post-ESD stenosis occurred in 10 (21.3%) of the 47 cardia cases and 14 (3.2%) of the 432 antrum cases. A wide resection of more than three fourths of the circumferential extent was the sole significant risk factor related to post-ESD stenosis in both cardia and antrum. Prophylactic endoscopic balloon dilation (EBD) was performed in 3 of 10 patients with cardiac stenosis and 4 of 14 with antral stenosis. Post-EBD bleeding occurred in one cardia (10%) and one antrum (7.1%) case each and was endoscopically treated. Perforation during EBD occurred in two (14.3%) antrum cases, both of which required emergency open surgery. All complications were observed in patients with conventional EBD, and no complications were associated with prophylactic EBD. A wide resection of more than three fourths of the circumferential extent was the significant risk factor for post-ESD stenosis in both cardia and antrum, and prophylactic EBD could be a promising procedure for the management of post-ESD stenosis.

Eliminating routine upper gastrointestinal contrast studies after sleeve gastrectomy decreases length of stay and hospitalization costs

BackgroundRecent series have shown the lack of value of routine upper gastrointestinal (UGI) contrast studies on postoperative day 1 or 2 for the detection of gastric leak (GL) after sleeve gastrectomy (SG). Despite this finding, many centers still perform routine early UGI contrast studies after SG. No series has evaluated the impact of eliminating this examination on the overall management of patients undergoing SG. ObjectivesTo evaluate the impact of UGI contrast studies on SG management. SettingUniversity hospital, France, public practice. MethodsThis study was an ambispective study of a cohort of patients who underwent primary SG between January 2014 and December 2014 (n = 267). Two consecutive groups were compared: patients with routine UGI contrast studies on postoperative day 1 (UGI+group, n = 154) and patients without routine UGI contrast studies (UGI−group, n = 113). The efficacy endpoint of the study was the overall impact of not performing routine UGI contrast studies (length of hospital stay, radiological data, rehospitalization data, and economic assessment). ResultsThe overall complication rate was 9.3% and no deaths were observed. The GL rate was 1.5%. The mean hospital stay was 1.8 days (2.1 days versus 1.5 days; P = .57). Routine UGI contrast studies did not detect any cases of GL or gastric stenosis. After UGI contrast studies, 56 patients complained of events related to UGI contrast studies (36.4%). A total of 27 computed tomography scans were performed during the first 3 postoperative months (16 in the UGI+group (10.4%) versus 11 in the UGI−group (9.7%); P = .52). Twelve patients were rehospitalized (7 and 5; P = .6). The median length of rehospitalization was 7 days (7 and 5 days; P = .6). Overall cost per patient during SG hospitalization was $5,219 in the UGI+group and $3,678 in the UGI−group (P = .01). ConclusionEliminating routine UGI contrast studies was associated with decreased length of hospital stay and cost of SG procedures. Larger series are required to show that not performing routine UGI contrast studies has no impact on the postoperative complication rate and the management of these complications.

How to treat stenosis after sleeve gastrectomy?

BackgroundLaparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Numerous articles have been written about the different approaches to the management of gastric fistulas, but limited data can be found concerning gastric stenosis after LSG. SettingPrivate hospital, France. MethodsA total of 18 patients received endoscopic treatment for stenosis after LSG between May 2007 and June 2015. Stenosis was classified according to the endoscopic findings as functional (the passage of the endoscope was possible, but the sleeve was twisted with various degrees of rotation) or mechanical (the passage of the endoscope was very difficult or impossible). ResultsThis study included 13 women and 5 men, with an average age of 37.2±8.4 years and an average body mass index of 41.6±8.7 kg/m2. The average number of endoscopic procedures was 1.3 (range, 1–4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4%, with one patient requiring conversion to Roux-en-Y gastric bypass. The mean time from the LSG to the first endoscopic intervention was 28.2 days. All patients presented with midsleeve stricture, located near the incisura angularis, and no patient showed a stenosis in the upper part of the gastric tube. ConclusionsThe treatment of stenosis after LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilation and stent deployment are useful and safe tools and must be used when appropriate.

A Rare Case Report of Severe Isolated Pre Pyloric Stenosis Developed Forty Days after Accidental Lye Ingestion

Introduction: Lye is an alkali tends to cause a more uniformly severe mucosal injury to the esophagus and limited gastric injury as its action is buffered by acid of gastric mucosa. We report a rare case of isolated severe pre pyloric stenosis without formation of esophageal stenosis developed forty days after accidental lye ingestion. Case report: 76 year old female with past medical history of dementia, hypertension, diabetes mellitus, hypothyroidism and accidental lye ingestion forty days ago subsequently developed grade 2B esophagitis, gastritis, erythematous duodenopathy and multiple non-obstructing duodenal ulcers on initial endoscopy (Picture 1) on day 2 of lye ingestion found to be improved on follow up endoscopy on day 14 (Picture 2) then eventually resumed on oral feeding; discharged to subacute nursing home facility. She presented on day 40 with complaint of intermittent nausea and non-bloody post-prandial vomiting for approximately 1 week. Patient denied any fever, dysphagia, abdominal pain and diarrhea. Vital signs on presentation were within normal limits. Physical examination was unremarkable for any swelling in neck and benign abdomen with active bowel sounds. Laboratory results were unremarkable. Patient was kept NPO, started on intravenous fluids and proton pump inhibitors. Barium swallow was done which showed poor transit across the antrum and pylorus. Endoscopy was done which showed moderately severe reflux esophagitis, a large amount of food in the stomach, scar in the gastric antrum and severe intrinsic pre pyloric stenosis. We were unable to advance endoscope or place a PEG tube safely (Picture 3). Eventually patient was started on total parental nutrition and prepared for gastrojejunostomy. Discussion: Acid is said to “lick the esophagus and bite the pyloric antrum”, alkali tends to cause a more uniformly severe mucosal injury to the esophagus and limited gastric injury. Isolated pre pyloric stenosis without esophageal stricture formation is the rarest complication of lye (alkali) ingestion most commonly occurs 6 to 12 weeks after initial ingestion but it may appear even after several years. Gastric stenosis most frequently found after acid ingestion although some cases of gastric stenosis have been reported after alkaline ingestion. Diligent follow-up after lye ingestion is advised to ensure patient has satisfactory gastrointestinal function restored and to correct late onset complications.Figure 1Figure 2Figure 3

Novel Lumen-Apposing Metal Stent for Treatment of a Benign Gastric Stricture after Caustic Injury

A 69 year old female developed extensive mucosal injury (Zargar Grade 2b) of her esophagus and stomach caused by accidental ingestion of a caustic alkali substance. Eight days after injury, EGD showed esophageal fibrosis with a stricture in the mid-esophagus, diffuse erythema of the stomach and a large ulcer encompassing a large portion of the antrum. The patient underwent a percutaneous endoscopic gastrostomy (PEG) with a 16 French PEG tube confirmed to be 5 cm away from the ulcer. Two weeks after PEG tube placement, the patient reported persistent sialorrhea. Endoscopy revealed worsening of the esophageal stricture and via fluoroscopy, the total length was determined to be 10 cm, with a diameter of 3 mm in the narrowest segment. The patient underwent multiple through-the-scope (TTS) guidewire-assisted endoscopic balloon dilations (EBD) of this esophageal stricture. She then began to have intractable nausea and vomiting after each bolus of tube feeds, and serial measurements of gastric residual volume (GRV) were increasingly elevated. Repeat endoscopy showed a tight prepyloric stricture secondary to the healing antral ulcer, and the PEG tube was replaced with a 16 French PEG tube with jejunal extension (PEG-J). Eleven days after placement, due to retrograde migration of the J-tube, the PEG-J tube was removed. The decision was made to place a novel lumen-apposing self-expandable metal stent (LAMS). A guidewire was inserted into the stomach through the existing gastrostomy tract and was advanced beyond the prepyloric stricture. A 10 mm x 10 mm LAMS (AXIOSTM Stent, Boston Scientific, Marlborough, Massachusetts, USA) was advanced over the guidewire and positioned across the prepyloric stricture with endoscopic and fluoroscopic guidance. This was followed by placement of a 16 French PEG tube into the stomach via the existing gastrostomy tract. During the 12 weeks after stent placement, the area remained patent with no evidence of migration or erosion, and the patient has been able to tolerate tube feedings well with appropriate weight gain. The use of LAMS for treatment of benign strictures can serve as a safe alternative treatment to EBD. Furthermore, the risk of migration, which has been associated with use of traditional fully-covered self-expandable metal stents is potentially lower with LAMS.Figure 1Figure 2

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

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.

Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series

BackgroundLaparoscopic sleeve gastrectomy (LSG) is accepted as a stand-alone bariatric procedure. A specific and potentially severe complication of LSG is gastric stenosis (GS). ObjectiveReviewing the treatment and prevention of GS after LSG. SettingUniversity hospital, Taiwan. Materials and MethodsA retrospective analysis was conducted involving all of the LSG cases (n = 927) at our institution between February 2007 and December 2015. ResultsEight patients (0.8%) with GS were identified in our unit and 1 patient was transferred from another institution with symptomatic GS. The median intervals from initial LSG to the presence of symptoms, endoscopic dilation, and surgical revision were 14±30 days (range, 7–103 days), 21±35.6 days (range, 9–110 days), and 36±473.9 days (range, 11–1185 days), respectively. The majority of stenoses were located at the incisura angularis (8/9 [88.9%]). Among the 9 patients, only 1 responded satisfactorily to repetitive endoscopic dilation and the remaining 8 patients required revisional laparoscopic surgery, including conversion to Roux-en-Y gastric bypass (n = 6), stricturoplasty (n = 1), and Roux-en-Y gastric bypass after failed seromyotomy (n = 1). No patients experienced recurrent symptoms of GS after revisional surgery. In September 2013, we modified our surgical techniques for the subsequent 489 patients and GS did not occur after the change in surgical procedures. ConclusionA combined treatment modality, endoscopic intervention with and without surgical revision is essential for managing GSs. Based on our own experience, we emphasize the clinical significance of surgical standardization to prevent the occurrence of GS.

Laparoscopic sleeve gastrectomy conversion to Roux-en-Y gastric bypass: experience in 50 patients after 1 to 3 years of follow-up

BackgroundSleeve gastrectomy (SG) is currently one of the most frequently performed bariatric interventions worldwide due to its simplicity and good weight loss results. Nevertheless, SG failure and complications are increasingly being observed as the number of procedures increases. ObjectivesTo report our results in converting SG to revisional laparoscopic Roux-en-Y gastric bypass (R-LRYGB). SettingUniversity Hospital, Chile. MethodsRetrospective analysis of our bariatric surgery database. Patients who underwent R-LRYGB after SG between June 2005 and April 2015 were identified. Demographic characteristics, anthropometrics, preoperative workup, and perioperative data were retrieved. Total weight loss (TWL), excess weight loss (EWL), and clinical progression over 3 years were registered. ResultsFifty patients were identified, mean age 39±8.4 years, 42 (84%) women; median body mass index previous to R-LRYGB was 33.8 (31–36) kg/m2. Indications for revision were weight regain (n = 28, 56%), gastroesophageal reflux disease (n = 16, 32%), and gastric stenosis (n = 6, 12%). In weight-regain patients, mean follow-up at 3 years was 72.2% and median percentage of total weight loss at 12 and 36 months was 18.5 (12–24) and 19.3 (8–23), respectively; percentage of excess weight loss at 12 and 36 months was 60.7 (37–82) and 66.9 (26–90), respectively. Over 90% of gastroesophageal reflux disease patients resolved or improved symptoms. All patients with gastric stenosis resolved symptoms after conversion. There were no major complications. ConclusionR-LRYGB is a feasible, effective, and well-tolerated alternative in selected patients with failed SG in which other therapies have been insufficient to either maintain weight loss or resolve complications. However, long-term follow-up is still needed.

New endoscopic technique for the treatment of large gastric fistula or gastric stenosis associated with gastric leaks after sleeve gastrectomy

BackgroundCovered stent (CS) is required when gastric leak (GL) after sleeve gastrectomy is combined with gastric stenosis (GS) or when a large (>2 cm in diameter) gastric fistula is present (increasing the likelihood of double pigtail stent [DPS] migration). ObjectiveTo compare the results of our previous endoscopic management of large GL or GS associated with GL (using CS only) with those of our new endoscopic treatment (using combined CS and DPS). SettingUniversity hospital, France, public practice. Material and methodsBetween January 2009 and June 2015, all patients treated for large GL or GS associated with GL after sleeve gastrectomy (n = 20 patients) were included. Our previous endoscopic management required CS placement (CS group), whereas our new endoscopic treatment required combined CS and DPS placement (CS+DPS group). The primary efficacy endpoint was the treatment duration after CS placement until closure of the GL. The secondary efficacy endpoints were the number of endoscopic procedures, the stent migration rate, and the failure rate. ResultsNine patients were treated by CS only (CS group), whereas 11 patients were treated by both CS and DPS (CS+DPS group). The median time to GL closure after CS placement was 84 days (33–130) in the CS group and 32 days (26–89) in the CS+DPS group (P≤.05). The median number of endoscopic procedures at the time of CS placement was 2 (1–3) in the CS group and 1 (1–2) in the CS+DPS group (P≤.05). The stent migration rate after CS placement was 33.3% in the CS group and 0% in the CS+DPS group (P = .21), and the failure rate was 11% and 0% (P = .36). ConclusionThe combination of CS and DPS constitutes an effective treatment for large GL or GS associated with GL, allowing significantly fewer endoscopic procedures and a shorter treatment duration.