Gastrojejunal Anastomotic Stricture Research Articles

S3400 The Vanishing LAMS: Lumen-Apposing Metal Stent Migration in the Setting of Gastrojejunal Anastomotic Stricture and Marginal Ulceration Post Roux-En-Y Gastric Bypass

S3400 The Vanishing LAMS: Lumen-Apposing Metal Stent Migration in the Setting of Gastrojejunal Anastomotic Stricture and Marginal Ulceration Post Roux-En-Y Gastric Bypass

Laparoscopic Repair of Type III Paraesophageal Hernia [PEH], Incidental Repair of Large, Incarcerated Retrocolic Mesocolon Hernia, and Hand-Sewn Revision of Recurrent Gastro-Jejunal Anastomotic Stricture After POSED Not Amenable to Endoscopic Dilatation and Stenting.

Laparoscopic Repair of Type III Paraesophageal Hernia [PEH], Incidental Repair of Large, Incarcerated Retrocolic Mesocolon Hernia, and Hand-Sewn Revision of Recurrent Gastro-Jejunal Anastomotic Stricture After POSED Not Amenable to Endoscopic Dilatation and Stenting.

Gastrojejunal Anastomotic Stricture Following Roux-en-Y Gastric Bypass: an Analysis of Anastomotic Technique at a Single Institution.

Patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) are at risk of developing strictures of the gastrojejunal anastomosis (GJA). Several variables can affect this, one of which may be the method of anastomosis. Between 2010 and 2014, our institution utilized three different anastomotic techniques for creating the GJA (25mm end-to-end circular-stapled (CS), linear-stapled (LS), and robotic hand sewn (HS)). Our objectives were to compare the method of GJA relative to the subsequent development of anastomotic stricture. We queried our electronic health record for all patients who underwent an upper endoscopy (EGD) after RYGB (2010-2014). Patient charts were retrospectively reviewed for type of GJA, weight loss, complications, interventions, and revisions of the GJA. In total, 1112 RYGB were performed at our institute, and 17.4% of patients (194/1112) had an upper endoscopy (EGD). Overall, 3.1% (34/1112) were found to have a stricture of the GJA. Patients undergoing a CS, LS, and HS anastomosis had GJA stricture rates of 4.9%, 0.5%, and 1.2% respectively (CS to LS (p < 0.05), p = NS among CS vs. HS, and LS vs. HS). The rate of GJA revision was 1.5%, 0.5%, and 0.1% (p = NS). In patients who had an EGD, excess BMI loss was 57.4%, 64.6%, and 59.2% (p = NS). In patients symptomatic from strictures, excess BMI loss was 69.4%, 83%, and 63.5% respectively (p = NS). The anastomotic technique for creating of the GJA may impact the formation of strictures. Based on our experience, gastrojejunostomies created with a 2-mm EEA-stapling technique are at higher risk of strictures.

Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review.

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

Endoscopic balloon dilation for gastrojejunal anastomotic stricture after Roux‐en‐Y gastric bypass: A case series

AbstractRoux‐en‐Y gastric bypass (RYGB) is an effective bariatric procedure but is encountered with gastrojejunal (GJ) anastomotic stricture as a major complication. We aimed to evaluate the efficacy and complications of endoscopic balloon dilation in the management of GJ anastomotic stricture after RYGB. Patients who underwent balloon dilation for GJ anastomotic stricture secondary to RYGB between March 2009 and April 2013 in E‐Da hospital were reviewed retrospectively. A smaller balloon size (8 mm) was routinely chosen initially and the balloon size was increased gradually. Dilation was stopped if the patients felt abdominal pain or up to 15 mm in size. Thirteen patients (nine men and four women) with a median age of 26 years (range 20‐42 years) and a median body mass index of 41.5 kg/m2 (range 35.3‐65.4 kg/m2) were enrolled. Anastomotic size ranged from 1 to 4 mm. The median interval between surgery and the first dilation was 43 days (range 20‐112 days). Nine patients (69.2%) required only one dilation, three (23.1%) required two dilations, and one (7.7%) required three dilations. Seven patients (53.8%) had anastomotic ulcers. Two patients had perforation and were treated conservatively. Twelve patients (92.3%) were successfully treated by balloon dilation. One patient was found to have a total obstruction 4 months after the first dilation and underwent operation. This study suggests that endoscopic balloon dilation is effective in the management of GJ anastomotic stricture after RYGB and most of the patients responded to one dilation session. Although perforation occurred, it can be treated conservatively in our case series.

S2343 Lumen-Apposing Metal Stent for Treatment of Gastro-Jejunal Stricture Following Roux-en-Y Gastric Bypass

INTRODUCTION: Roux-en-Y Gastric Bypass (RYGB) is the second most common bariatric procedure for weight loss. Gastro-Jejunal (GJ) anastomotic strictures occur in up to 7% of cases. Endoscopic balloon dilation is considered the gold standard for GJ strictures; however, in some cases, it fails to deliver. We present a case in which a refractory GJ anastomotic stricture, after RYGB, was resolved by a novel treatment option. CASE DESCRIPTION/METHODS: A 43-year-old female with an extensive past surgical history including a hiatal hernia repair after Lap-Band and a revision of a sleeve for a kink underwent a laparoscopic sleeve gastrectomy conversion to RYGB for severe reflux. Two days after RYGB, the patient developed dysphagia due to GJ stricture for which she had multiple unsuccessful balloon dilation attempts. It was decided that a lumen-apposing metal stent (LAMS) be used to treat this stricture. The stent was then endoscopically removed in 1 month. Upon removal, the GJ anastomosis appeared patent with healthy-appearing efferent and afferent limbs. The patient now has a patent gastrojejunostomy and can tolerate PO intake. DISCUSSION: GJ anastomotic stricture is a potential complication of RYGB. Serial pneumatic dilation is the traditional endoscopic management. Alternatives include the use of a fully covered self-expanding metal stent (fcSEMS), although a high rate of migration has been reported. LAMS has been increasingly used throughout the gastrointestinal tract; its dumbbell shape design minimizes the risk of migration. This case demonstrates the successful use of LAMS in treating GJ stricture after RYGB.Figure 1.: Gastro-Jejunal anastomotic stricture.Figure 2.: Endoscopic view of Lumen-Apposing Metal Stent.Figure 3.: Resolution of Gastro-Jejunal anastomotic stricture.

2123 The Vanishing Gastrojejunostomy: A Case Report

INTRODUCTION: Gastrojejunal anastomotic strictures or stenoses are well recognized complications from Roux-en-Y gastric bypass surgery. Endoscopy remains an effective and safe means to diagnose these complications, which can occur as early as one month after surgery. The two main treatment modalities include endoscopy, either with balloon or bouginage dilators, or open versus laparoscopic surgery. Despite direct visualization, endoscopy could easily miss a severely stenotic anastomosis, as illustrated in the case of our a patient with gastrojejunal stenosis status post gastric bypass surgery. CASE DESCRIPTION/METHODS: 43-year-old man with past medical history of morbid obesity s/p laparoscopic Roux-en-Y was admitted for acute nausea and vomiting. The Rouz-en-Y was performed one month ago and he initially was doing well with expected weight loss. Over the last 10 days, he had persistent nausea, vomiting, and anorexia. Labs were unremarkable at presentation. Initially, the surgical team was consulted and performed an EGD which revealed severe stenosis at the gastrojejunal anastomosis site; a balloon dilator was not able to be passed through the stenosis. The following day, gastroenterology team performed a repeat EGD, which revealed a large hematoma in the gastric body and epinephrine was injected. Initially, the gastrojejunal anastomosis was not clearly visualized despite partial dislodgement of the clot. However, under fluoroscopy, a closed, possible anastomotic site was identified and a wire was advanced through with contrast injection for verification that the wire was in fact in the bowel lumen. The anastomosis was then dilated and an AXIOS stent was placed across the anastomosis. The patient recovered well post-operatively, tolerating PO intake and was discharged. At follow up, the stent was successfully removed via rat-toothed forceps without complication. The anastomotic site was friable, but was wide open and a standard gastroscope was easily advanced through without complications. DISCUSSION: Gastrojejunal anastomotic stenosis is a known complication of Roux-en-Y gastric bypass surgeries. Its etiology is not completely understood and likely multifactorial but treatment options include endoscopic dilation and surgery. For our patient, fluoroscopic guidance with wire placement through the anastomotic site was required for successful deployment of the AXIOS stent. Therefore, endoscopic diagnosis should be considered as a safe modality for diagnosis and intervention for these complications.

2188 Off-label Use of Lumen-Apposing Metal Stent for Gastro-Jejunal Anastomotic Stricture Following Roux-en-y Gastric Bypass

INTRODUCTION: Roux-en-y gastric bypass (RYGB) is the second most common bariatric surgery performed after sleeve gastrectomy. A complication of this procedure is a gastrojejunal (GJ) anastomotic stricture. A lumen apposing metal stent (LAMS), which was initially used for draining pancreatic fluid collections/cystogastrostomy, is now being used in various locations throughout the gastrointestinal tract due to its novel dumbbell shaped design. In this case report we present a case of GJ anastomotic stricture successfully managed with LAMS after failure of serial balloon dilations. CASE DESCRIPTION/METHODS: A 51-year-old woman with a history of RYGB in 2008, complicated by recurrent stricture of her GJ anastomosis, presented for treatment options of her stricture. She had undergone dilations in the past with no change in her symptoms of daily vomiting. The patient requested a more definitive treatment. The patient was taken for placement of a LAMS endoscopically. Her stricture at the GJ anastomosis measured 7mm in diameter and &lt;1 cm in length. A hydrophilic wire was inserted into the jejunum under fluoroscopic guidance. A 15mm LAMS was advanced over the wire into the jejunal lumen. Placement was confirmed with endoscope and fluoroscopic image. Finally, a 12-13.5-15 mm CRE balloon was advanced over the wire and used to dilate the lumen of the stent. The patient returned to the clinic 5 weeks later with complete resolution of her symptoms. She will have the stent removed in 2 weeks. DISCUSSION: GJ anastomoses can initially be managed with pneumatic dilations. However, this requires repeat interventions with limited success. A common alternative is the fully covered self-expanding metal stent (FCSEMS). The FCSEMS has a high rate of adverse events including stent migration, perforation, and recurrence of strictures after removal. A LAMS has a novel dumbbell shape design that prevents leakage and migration due to 24 mm anchoring flanges, while also being shorter and smaller than FCSEMS. Additionally, because of the dumbbell shape, when inflated with a CRE balloon, the risk of migration is very low. For these reasons, in addition to its expanding use within the GI tract, it was used in our patient with success. This case demonstrates another use for LAMS that is safe and effective in an expanding population.

2116 Salvage Therapy for Recurrent Gastrojejunal Anastomotic Stricture Using a Lumen-Apposing Metal Stent

INTRODUCTION: Gastrojejunal (GJ) anastomotic stricture following Roux-en-Y gastric bypass is a well-known complication of the surgery with reported ranges varying from 2.9-23%.1 Unfortunately, prior endoscopic interventions for these strictures have had limited durability of treatment response. CASE DESCRIPTION/METHODS: A 71-year-old male with previous Roux-en-Y gastric bypass presented to our hospital with 2 weeks of nausea, vomiting, weight loss, and severe hypoglycemia. Initial imaging with CT abdomen showed a fluid-filled and distended gastric pouch with likely stenosis of the GJ anastomosis. An upper GI series was performed which confirmed significant stenosis at the GJ anastomosis (Figure 1a). An EGD was performed at which time the stricture was successfully dilated using a through-the-scope (TTS) 6-7-8 mm and then an 8-9-10 mm balloon dilator (Figure 2). Unfortunately, the patient did not clinically respond to dilation and was unable to advance diet beyond liquids, requiring initiation of total parenteral nutrition. Subsequently, the patient underwent a repeat EGD with placement of a 20 mm × 10 mm lumen apposing metal stent (LAMS) (Axios, Boston Scientific) under fluoroscopic guidance. The stent was successfully dilated with a TTS 12-13.5-15 mm balloon dilator to a maximal size of 13.5 mm with obliteration of the waist. The LAMS was then sutured into place with the endoscopic suturing device (OverStitch, Apollo Endosurgery, Inc) using 2.0 polypropylene suture and placing 2 interrupted sutures with cinches on both ends (Figure 3). An upper GI series was repeated 24 hours after LAMS, which showed excellent functioning of the stent without leak or obstruction (Figure 1b). Over the next five days, the patient’s symptoms abated, diet was gradually advanced to low residue diet, TPN was discontinued, and the patient was discharged home. DISCUSSION: Management of these strictures has primarily been pneumatic balloon dilation or fully covered self-expanding stents; however, dilation is unlikely to achieve durable response and other stents are associated with complications of stent migration and recurrence of symptoms after removal. Previous case reports have documented successful treatment of GJ anastomotic strictures using LAMS with excellent response given its novel shape and anchoring phalanges. 1 We further show the successful endoscopic suturing of the LAMS, which will allow for prolonged time for stent placement with enhanced risk-mitigation for stent migration.

Post Roux-en-Y gastric bypass complications: A comparative study assessing the clinical effectiveness of oesophagogastroduodenoscopy and oral-contrast swallow

IntroductionAnastomotic strictures at the gastrojejunal anastomosis have been reported to occur in 3–20% of patients following a Roux-en-Y gastric bypass (RYGB). Patients commonly present with dysphagia, vomiting and post-prandial pain. Clearly using the appropriate investigations to diagnose the potential complications have both clinical and economical benefits. The reported study compared whether Oesophagogastroduodenoscopy (OGD) or oral-contrast swallow should be employed in patient presenting with post-operative complications following RYGB. MethodsA retrospective study was conducted on 112 patients between 2008 and 2012; at a level 4 bariatric surgery hospital. Patients who had ≥1 OGD to investigate a post-operative complication were included for analysis. Oral-contrast swallow radiology reports performed <28 days prior to an OGD were included for analysis. Patient demographics, OGD, oral-contrast swallow and additional interventions reports were collated from electronic records, pathology and radiology results. Results112 patients underwent 1 or more OGD. 75% (n = 67) of patients were diagnosed with a post-operative complication with the most common, 51% (n = 57) being a gastrojejunal anastomotic stricture. 82% (n = 47) of patients presented with dysphagia + - vomiting prior to the diagnosis of gastrojejunal anastomotic strictures. 96% (n = 55) of patients with gastrojejunal anastomotic strictures were successfully treated with balloon dilation. 48% (n = 54) of patients had an oral-contrast swallow as a first line investigation for post-operative symptoms prior to the OGD. 15% (n = 8) of oral-contrast swallow were reported with a significant pathology, with only 1 stricture identified. 70% (n = 38) of oral-contrast swallows reported as normal had a pathology identified at OGD, including 28 strictures. ConclusionWe recommend that an OGD should be performed in patients presenting with symptoms consistent with a stricture following RYGB. The urgency of the OGD will be dictated by clinical correlation. The use of a water-soluble contrast swallow should be reserved for a suspected anastomotic leak.

Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery

IntroductionRoux-en-Y gastric bypass is a commonly used technique of bariatric surgery. One of the most important complications is gastrojejunal anastomotic stricture. Endoscopic balloon dilation appears to be well tolerated and effective, but well-designed randomized, controlled trials have not yet been conducted. ObjectiveIdentify factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. SettingGastrointestinal endoscopy service, university hospital, Brazil. MethodsThe records of 64 patients with anastomotic stricture submitted to endoscopic dilation with hydrostatic balloon dilation were reviewed. Information was collected on gastric pouch length, anastomosis diameter before dilation, number of dilation sessions, balloon diameter at each session, anastomosis diameter after the last dilation session, presence of postsurgical complications, endoscopic complications, and outcome of dilation. Comparisons were made among postsurgical and endoscopic complications; number of dilations, balloon diameter; anastomosis diameter before dilation; and dilation outcome. ResultsSuccess of dilation treatment was 95%. Perforation was positively and significantly associated with the number of dilation sessions (P = .03). Highly significant associations were found between ischemic segment and perforation (P<.001) and between ischemic segment and bleeding (P = .047). Ischemic segment (P = .02) and fistula (P = .032) were also associated with dilation failure. ConclusionIschemic segment and fistula were found to be important risk factors for balloon dilation failure. The greater the number of dilation sessions, the greater the number of endoscopic complications.

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

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.

Lumen-apposing metal stent for the treatment of refractory gastrojejunal anastomotic stricture after laparoscopic gastric bypass

Lumen-apposing metal stent for the treatment of refractory gastrojejunal anastomotic stricture after laparoscopic gastric bypass

The Effect of Route of Anvil Insertion on Stricture Rates with Circular Stapled Gastrojejunostomy During Laparoscopic Gastric Bypass.

A higher incidence of gastrojejunal (GJ) anastomotic strictures has been reported following laparoscopic gastric bypass (LRYGB) with the 21 mm compared to 25 mm circular stapler. We hypothesized that the rate of stricture formation is affected by route of anvil insertion and its position relative to the gastric pouch staple line [trans-gastric above staple line (trans-gastric) vs. trans-oral through staple line (trans-oral)] following LRYGB. Retrospective review of consecutive patients who underwent LRYGB with circular stapled GJ studied in four groups: trans-gastric-21 mm, trans-gastric-25 mm, trans-oral-21 mm, and trans-oral-25 mm. Primary outcome studied was GJ stricture; secondary outcomes were results with endoscopic therapy and weight loss at 12 months. Predictors studied were age, gender, body mass index (BMI), comorbidities, and operative technical factors including anvil size and insertion route. Regression analyses were performed to identify predictors of GJ stricture. Eight hundred seventy-six patients underwent LRYGB. Seventy-six (8.7 %) developed a GJ stricture. The highest stricture rate occurred in the trans-gastric-21 mm group (17 %, p < .01 for all comparisons). Stricture rates were similar for trans-gastric-25 mm (8.4 %), trans-oral-21 mm (5.2 %), and trans-oral-25 mm (1.6 %) groups. Independent predictors of stricture were: trans-gastric-21 mm (OR 10.9, 95%CI 1.4-85.1; p = .022) and age (OR 0.97, 95%CI 0.95-0.99; p = .002). Endoscopic dilation relieved symptoms in all patients. There was no difference in %EWL at 12 months in patients with and without a stricture. We conclude that the trans-oral-21 mm anvil is associated with a low stricture rate. With the advantage of smaller abdominal wall wound, trans-oral-21 mm may be the preferred size and route of anvil insertion.

Gastrojejunostomy stricture rate: comparison between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass

BackgroundRoux-en-Y gastric bypass procedure is an effective treatment for morbid obesity. One of the most frequent complications after this operation is the appearance of a gastrojejunal anastomotic stricture. Mechanisms underlying the development of such complication are unclear. Objective: The aim of the present retrospective study was to compare the rates of gastrojejunostomy stricture between the antecolic and retrocolic technique in a large cohort of patients undergoing Roux-en-Y gastric bypass for morbid obesity, with the same gastrojejunal anastomotic technique. SettingUniversity Hospital, France. MethodsFrom November 2000 to March 2012, 1500 patients underwent laparoscopic Roux-en-Y gastric bypass. The antecolic and the retrocolic technique were used in respectively 572 and 928 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy and absorbable sutures. ResultsThere was no significant difference with respect to gender, age, body mass index, and obesity related co-morbidities between both groups. Patients were followed for 24–146 months (mean 67.5 mo). Fifty-one patients developed a gastrojejunal stricture (3.4%), 37 in the antecolic group (6.5%) and 14 in the retrocolic group (1.5%). The difference was significant (P< .0001). The mean time to onset of gastrojejunal stricture symptoms after surgery was 1 month, ranging from 1 to 3 months. All patients were successfully treated using Savary-Gilliard dilatators. All patients with a gastrojejunal stricture were followed up for a minimum of 36 months. No recurrence was observed and no revisional surgery was needed. Weight loss was similar in patients who developed an anastomotic stricture compared with those without stricture. In the antecolic group internal hernia occurred in 12 of the 110 with no closure of mesenteric defects and in 8 of the 462 (1.7%) with defects closed. In the retrocolic group, 11 patients (1.2%) developed an internal hernia. ConclusionsA significant lower gastrojejunal stricture rate was observed in the retrocolic group, with no increased risk of internal hernia, when mesenteric defects were closed. The antecolic technique seems to be a risk factor for gastrojejunal stricture development after laparoscopic gastric bypass.

Secondary stent-in-stent self-expanding metallic stent placement for early stent occlusion due to mucosal oedema in the gastrojejunal anastomosis after palliative subtotal gastrectomy for locally advanced gastric cancer

Herein, we report a case of early in-stent occlusion due to the ingrowth of soft oedematous mucosal tissue through the lattices of an uncovered stent, which was used for palliation of a postoperative gastrojejunal anastomotic stricture. The in-stent occulsion was treated with the deployment of a second stent, which was covered, within the first stent. This led to successful resolution of the occlusion.

Gastro-jejunal Obstruction Caused by Clotting after Gastric Bypass Surgery: A Case Series

Purpose: One of the most frequent surgical modalities for the treatment of obesity is the Roux-en-Y gastric bypass (RYGB). Previously described complications of RYGB include stomal stenosis, gastric staple line dehiscence, leaks, jejunal and gastric wall necrosis, and loculated fluid collections. Another reported complication is post-operative intraluminal bleeding, which is usually self-limiting. However, it is uncommon to encounter early gastric outlet obstruction secondary to intraluminal blood clots. Intraluminal blood clot formation causing obstruction post RYGB has been reported in only a few case reports, where management predominantly included laparotomy and surgical revision. We report a case series of three patients who developed intraluminal blood clots at the gastro-jejunal anastomosis following robotically-assisted RYGB occurring within 72 hours of surgery. Our first case involves a 63-year-old woman with morbid obesity (BMI 42) who presented with persistent nausea and vomiting for 3 days after an elective, robotically-assisted RYGB and laparoscopic lysis of adhesions. After the procedure, the patient underwent a routine upper GI series without evidence of leakage from the visualized pouch; however, there was no evidence of emptying into the alimentary limb. Physical exam revealed a distended abdomen which was appropriately tender to palpation at the surgical site. EGD was performed and a large blood clot was visualized at the anastomotic site, causing a gastric outlet obstruction. After unsuccessful attempts at irrigation of the clot, biopsy forceps were utilized to fragment the clot. Thereafter, an 8-mm balloon was advanced twice through the clot and inflated to successfully create a lumen. Case 2 and Case 3 include a 53-year old woman (BMI 46) and a 29-year old woman (BMI 43), respectively, who were both admitted for elective RYGB. Both patients experienced persistent nausea for 3 days after surgery. Upper GI series revealed retention of contrast in the gastric pouch, concerning for a gastro-jejunal anastomotic stricture. A subsequent EGD revealed friable, ulcerated, and granulated clot tissue at the gastro-jejunal anastomosis. Thus, a 10-mm gastroscope was passed across the surgical anastomosis to break the clot and relieve the obstruction allowing for passage into the alimenatary limb. Endoscopic dilation has become the elected treatment for gastrojejunal anastomotic stricture after RYGB, due to the low morbidity of this procedure. We highlight three cases of obstructing blood clots at the gastro-jejunal anastomosis managed endoscopically. Endoscopic evaluation and evacuation of clot and fibrinous material should be pursued prior to proceeding straight to laparotomy.

Perioperative outcome of Laparoscopic Roux-en-Y gastric bypass: A children's hospital experience

Background/PurposeTo evaluate the perioperative safety of laparoscopic Roux-en-Y gastric bypass (LRYGB) in a freestanding children's hospital setting. Patients and MethodsPerioperative (<90days) clinical complications of 77 consecutive patients (mean age 16.8±2.1years: mean BMI 59.4kg/m2, 68% female), who underwent LRYGB at Cincinnati Children's Hospital from 2002 to 2007 were examined, using standardized data collection forms that were created specifically for use in this study. ResultsNo mortality or conversion to open surgery was observed. Intraoperative complications were uncommon (3%). No anesthetic complications or transfusion requirements were observed. Median hospital stay was 3days. Twenty-two percent of subjects had a complication from discharge to 30days, while 13% experienced a complication between 31 and 90days. The common types of postoperative complications included gastrojejunal anastomotic stricture (17%), leak (7%), dehydration (7%), and small bowel obstruction (SBO; 5%). Reoperation was required in 9 subjects. Operating time significantly decreased as the number of cases performed increased. ConclusionsLRYGB in this case series of adolescents was associated with a low rate of intraoperative complications, with an increased rate over the ensuing 90days. These events can be successfully managed, even in super obese adolescents.

3 clips, 2 Stents, 1 Loop: A Novel Technique to Prevent Stent Migration in Strictures

Purpose: The incidence of gastrojejunal anastomotic stricture after RYGB is reported to be 3-22% and is the most common complication post gastric bypass. Although no formal definition exists, a gastrojejunal anastomotic stricture is loosely defined as a narrowing of the anastomosis that does not allow passage of a standard gastroscope (8.6-9.8 mm). The best nonsurgical treatment for strictures regardless of the underlying cause is stent placement as an alternative to surgery. The most common complication of stent placement is stent migration. Other complications include tissue ingrowth and stent erosions. Migration away from the initial anastomotic site continues to be a major issue and is reported in 12-66% of patients. Anchoring techniques to prevent stent migration have been reported and include endoscopic clips, polypectomy snare applied to the stent's retrieval lasso and fixed externally, and surgical suturing of the lasso. We present a case of endoloop and 3 clips to holster a Bonastent successfully to prevent migration in a patient who already had one previously placed stent migrated. A 48 year-old male with a history of a Roux-en-Y gastric bypass presented with dysphagia, nausea, and vomiting two months after surgery and recent Wallflex stent placement. He was unable to consume solids and was found to have a stricture at the gastrojejunal anastomotic site. He then proceeded to have an upper endoscopy where a post-anastomotic ulcer was also noted. The enteroscope was passed distally into the jejunum where the previously placed Wallflex stent was located and removed with a rat-toothed forceps. No dilation or re-stent was performed given the amount of tissue edema and the presence of the anastomotic ulcer which was not present on the previous endoscopy. A guide wire was advanced through the stricture and then dilated from 6-12 mm with a CRE balloon. After the dilation, the endoscope was easily able to enter the efferent jejunal limb, confirming the location of the wire. Under fluoroscopic guidance a fully-covered esophageal dogbone shaped Bonastent® (18 mm × 60 mm) was deployed. An endoloop was then placed around stent retrieval lasso, and three hemoclips were used to secure the loop to the gastric remnant to help prevent distal migration. Follow-up after 8 weeks, he continues to be asymptomatic, tolerating solids and liquids without any symptoms. To our knowledge this type of success has never been reported before. Stent migration and the need for close surveillance and revision are currently the most marked drawbacks of stents but this will likely be improved as stent manufacturers customize stent's shape for use in bariatric surgery.

Pathophysiological Factors Involved in Anastomotic Stricture Formation after Roux-en-y Gastric Bypass Surgery (RYGB)

Purpose: Recent surveys have shown that the prevalence of obesity in the U.S. has risen to 32%. There are 220,000 bariatric surgical procedures performed yearly in the U.S. and Canada; RYGB is the most common surgical treatment for morbid obesity in the U.S. RYGB reduces both medical complications and mortality in obese patients. A gastrojejunal (GJ) anastomotic stricture occurs in up to 27% of patients after RYGB, but the causes of postoperative strictures are poorly understood. This study was designed to evaluate factors that might increase the risk of GJ stricture formation after RYGB. Methods: This is a retrospective cohort study. Patients (n=165) who underwent open or laparoscopic RYGB from 6/2006 to 3/2011 and who were seen in our bariatric GI clinic at a large, urban community hospital were included. Medical records of all patients were reviewed. We recorded age, gender, ethnicity, body mass index (BMI), surgical technique, and possible factors that could contribute to postoperative stricture formation. The primary endpoint was identification of factors associated with GJ stricture formation. We also performed an analysis of the outcomes of endoscopic management of strictures. Statistical analysis was performed using Chi-squared testing and multivariate analysis. Results: There were 147 women and 18 men: 24.2% Caucasian- and 71.5% Black-Americans. Thirty-five patients (25.6%) developed GJ strictures. BMIs were not different between GJ stricture (mean 50 kg/m2) compared to no stricture (51.5 kg/m2). There was no significant difference in stricture formation in patients using NSAIDs, smoking or who had H. pylori or coronary artery disease. Stricture was more common (p=0.03) in older patients, Caucasians (p=0.005), patients with obstructive sleep apnea (OR 2.46, 95% CI 1.1456 to 5.3232, p=0.02), patients with marginal ulcer formation (OR 3.689, 95% CI 1.5075 to 9.0742, p=0.004), and patients taking proton pump inhibitors (OR 3.20, 95% CI 1.4734 - 6.99, p=0.003). All 35 GJ strictures in our study were successfully treated with endoscopic pneumatic dilation with a through-the-scope balloon dilator. An average of two sessions was required for symptomatic improvement, but 1 patient required 9 dilation sessions and then injection of Triamcinolone. Conclusion: Our findings show that age, ethnicity, obstructive sleep apnea, marginal ulcer formation and use of proton pump inhibitors are associated with statistically significant increased risk of GJ anastomotic stricture formation after RYGB surgery. Sleep apnea may increase the risk of ischemia. These findings will be used in the development of a prospective protocol. GJ strictures were successfully treated with balloon dilation, which required an average of two sessions.