Gastrojejunal Stricture After Gastric Bypass and Efficacy of Endoscopic Intervention

Abstract

The Roux-en-Y gastric bypass procedure (RYGBP) is an effective treatment for morbid obesity. Anastomotic strictures are a common complication after RYGBP. This study examines the frequency of post-RYGBP gastrojejunal strictures (GJS), methods of evaluation, and the outcome of endoscopic intervention. Medical records of patients who had RYGBP for morbid obesity at our institution during four consecutive years were reviewed for patient demographics, medical comorbidities, surgical technique, and outcomes. Radiographic and endoscopic findings of those patients suspected to have GJS were noted. The impact of patient-related variables and surgical technique on risk of GJS, time to diagnosis of GJS, and treatment outcomes for GJS was determined. Of 888 patients, 503 had open RYGBP (57%) and 385 laparoscopic RYGBP (43%). Ninety-four patients (10.6%) underwent esophagogastroduodenoscopy (EGD) for possible GJS and 58 (6.5%) were found to have anastomotic stricture. Laparoscopic RYGBP was associated with increased incidence of GJS (43/385, 11.1%) compared with open RYGBP (15/503 or 2.9%, P = 0.0003). A total of 125 dilations were performed with an average of 2.2 dilations per patient. None of the strictures needed surgical revision. There were four perforations (3.2%) related to EGD. Mean time to diagnosis of GJS was 66.2 days. Eighty-seven of 94 patients underwent radiologic upper gastrointestinal (UGI) evaluation prior to EGD. UGI evaluation demonstrated a positive predictive value (PPV) of only 66% [95% confidence interval (CI) 52-77], and negative predictive value (NPV) of 83% (95% CI 65-93). Laparoscopic GBP is associated with increased risk of GJS. Endoscopic dilation of GJS is an effective treatment with minimal risk. Radiographic studies appear to have poor specificity for diagnosis of GJS and have a low positive predictive value. EGD should be performed in all suspected cases of GJS.

Stenosis in laparoscopic gastric bypass: management by endoscopic dilation without fluoroscopic guidance

“…Some authors have obtained good results by Savary-Gilliard bougies (11). Although most prefer the use of through-the-scope (TTS) (4,5,8,10,12,(14)(15)(16)(17)(18). Our experience shows that the dilation of the stenosis of the stoma using TTS balloon is safe and effective.…”

“…Published studies are not clear when it comes to describing this aspect. The minority of them clearly manifest not using fluoroscopy during dilation (4,18), others claim to have used it in all or in one of their patients (5,6,8,11,16), and finally, others do not make any sort of comment in this regard in their publications (9,10,14,15,17). Our experience demonstrates that carrying out dilations in patients with stenosis of the anastomosis in the gastric bypass is possible without a fluoroscopic guidance, allowing carrying out the technique in the simplest manner, in the same endoscopy room, without radiation for the patient or for the medical staff, and probably for a shorter period of time.…”

“…The stenosis of the stoma (stenosis of the gastro-jejunal anastomosis) occurs in approximately 3-12% after gastric bypass, and must be suspected when the patient experiences dysphagia, nausea and vomiting (2)(3)(4)(5)(6)(7)(8)(9). Endoscopic dilation of the stenosis by means of a balloon or bougie is considered the treatment of choice, even if in most studies it is not quite clear whether it should be done with or without a radioscopic guidance (4)(5)(6)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18) In this study, we informed of our experience in the management of the stenosis of the stoma in patients with laparoscopic gastric bypass by means of endoscopic dilation with a hydrostatic balloon, without fluoroscopic guidance.…”

Evaluating the Effect of Drain Site on Abdominal Pain after Laparoscopic Gastric Bypass Surgery for Morbid Obesity: A Randomized Controlled Trial

“…14 In laparoscopic Roux-en-Y gastric bypass surgery, the authors state that the postsurgical abdominal pain might be related not only to the drain site but also to other etiologies, as different etiologies have been proposed to contribute to postsurgical abdominal pain, including rapid abdominal distension due to fast eating, 13 food intolerance and nutritional deficiency, 15 gastrointestinal dysfunction, 16,17 or changes in Oddi sphincter function due to gallbladder stones. 18 Gastric ulcer, 19,20 gastroesophageal reflux disease, 1,21,22 and stenosis in the anastomotic site may cause pain in 5-10% of patients, 23,24 trocar site hernia in 0-1%, adhesion band in 1-2%, 25,26 incisional hernia in 1-9%, 23,24 and intussusception in 1%. 26 Omental torsion, infarction, 27,28 and bezoar obstruction 29,30 are other suggested causes.…”

Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity

“…6), with a documented incidence ranging from 2.9% to 23.0% of patients. 31,32 Factors affecting the development of anastomotic strictures include tension or ischemia at the anastomosis and the healing capacity of individual patients. 30,33 It has been noted that this complication is substantially more frequent with the laparoscopic than the open approach.…”