Endoscopic balloon dilation of stomal stenosis following gastric bypass

Endoscopic Management of Surgical Complications of Bariatric Surgery

Bariatric surgery, although highly effective, may lead to several surgical complications like ulceration, strictures, leaks, and fistulas. Newer endoscopic tools have emerged as safe and effective therapeutic options for these conditions. This article reviews post-bariatric surgery complications and the role of endoscopy in their management.

Endoscopic Dilation of Bariatric RNY Anastomotic Strictures: a Systematic Review and Meta-analysis

Gastrojejunostomy anastomotic strictures are a complication of Roux-en-Y gastric bypass surgery without an established treatment guideline. A systematic review and meta-analysis were performed to determine the safety and efficacy of endoscopic dilation in their management. PubMed, Web of Science, and Cochrane Central (1994-2017) were searched. Data was analyzed with random effects meta-analysis and mixed effects meta-regression. Twenty-one observational studies (896 patients) were included. The stricture rate for laparoscopic patients was 6% (95% CI, 5-9%). Only 38% (95% CI, 30-47%) required greater than one dilation. Symptom improvement occurred in 97% (95% CI, 94-98%). The complication rate was 4% (95% CI, 3-6%). Endoscopic dilation of GJA strictures is safe, effective, and sustaining. This study can guide endoscopists in the treatment of a common bariatric surgical complication.

Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results

Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.

Endoscopic Approach for Major Complications of Bariatric Surgery

As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.

Endoscopic management of post-bariatric surgery complications

Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early (< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late (> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.

Endoscopy after bariatric surgery

Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.

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

INTRODUCTION

Roux-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.

OBJECTIVE

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

SETTING

Gastrointestinal endoscopy service, university hospital, Brazil.

METHODS

The 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.

RESULTS

Success 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.

CONCLUSION

Ischemic 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.

Roux-en-Y gastric bypass does not affect daily water intake or the drinking response to dipsogenic stimuli in rats

Bariatric surgery is currently the most effective treatment for severe obesity, and Roux-en-Y gastric bypass (RYGB) is the most common approach in the United States and worldwide. Many studies have documented the changes in body weight, food intake, and glycemic control associated with the procedure. Although dehydration is commonly listed as a postoperative complication, little focus has been directed to testing the response to dipsogenic treatments after RYGB. Accordingly, we used a rat model of RYGB to test for procedure-induced changes in daily water intake and in the response to three dipsogenic treatments: central administration of ANG II, peripheral injection of hypertonic saline, and overnight water deprivation. We did not find any systematic differences in daily water intake of sham-operated and RYGB rats, nor did we find any differences in the response to the dipsogenic treatments. The results of these experiments suggest that RYGB does not impair thirst responses and does not enhance any satiating effect of water intake. Furthermore, these data support the current view that feedback from the stomach is unnecessary for the termination of drinking behavior and are consistent with a role of orosensory or postgastric feedback.

Endoscopic dilation of gastrojejunal anastomosis after gastric bypass

INTRODUCTION

Roux-en-Y gastric bypass may result in stenosis of the gastrojejunal anastomosis. There is currently no well-defined management protocol for this complication.

AIM

Through systematic review, to analyze the results of endoscopic dilation in patients with stenosis, including complication and success rates.

METHODS

The PubMed database was searched for relevant studies published each year from 1988 to 2010, and 23 studies were identified for analysis. Only papers describing the treatment of anastomotic stricture after Roux-en-Y gastric bypass were included, and case reports featuring less than three patients were excluded.

RESULTS

The mean age of the trial populations was 42.3 years and mean preoperative body mass index was 48.8 kg/m². A total of 1,298 procedures were undertaken in 760 patients (81% female), performing 1.7 dilations per patient. Through-the-scope balloons were used in 16 studies (69.5%) and Savary-Gilliard bougies in four. Only 2% of patients required surgical revision after dilation; the reported complication rate was 2.5% (n=19). Annual success rate was greater than 98% each year from 1992 to 2010, except for a 73% success rate in 2004. Seven studies reported complications, being perforation the most common, reported in 14 patients (1.82%) and requiring immediate operation in two patients. Other complications were also reported: one esophageal hematoma, one Mallory-Weiss tear, one case of severe nausea and vomiting, and two cases of severe abdominal pain.

CONCLUSION

Endoscopic treatment of stenosis is safe and effective; however, further high-quality randomized controlled trials should be conducted to confirm these findings.

Sedation in the bariatric patient

Obesity is a significant health problem that has assumed epidemic proportions. A durable reduction in weight and improved morbidity and mortality have been realized with the introduction of various bariatric surgical procedures. It is unknown how safe the current practices of sedation for endoscopic procedures are in bariatric patients. Morbid obesity can result in pulmonary hypertension, obstructive sleep apnea, and restrictive lung disease. This article explores these issues and how they may impact the risk profile of current standards for endoscopic sedation.

Procedural sedation and obesity: waters left uncharted

BACKGROUND

Moderate sedation during endoscopy may pose increased risks among obese patients.

OBJECTIVE

To review the literature that considers aspects of sedation within the obese population and to identify gaps in our knowledge.

DESIGN

Literature-based review.

RESULTS

There may be increased risks among obese patients undergoing moderate sedation. In particular, the presence of obstructive sleep apnea may identify a subset of patients at higher risk for complications.

LIMITATIONS

English language literature only.

CONCLUSIONS

Although obesity may be associated with increased risks of procedural sedation, future studies should better clarify such risks to better inform clinical decision making.

Incidence of anastomotic strictures after gastric bypass: a prospective consecutive routine endoscopic study 1 month and 17 months after surgery in 441 patients with morbid obesity

BACKGROUND

Anastomotic stricture after gastric bypass for morbid obesity has been reported as the most frequent complication after surgery. The objective of this study is to determine in a prospective and consecutive endoscopic evaluation the true incidence of this complication early and late after gastric bypass.

METHODS

A total of 441 morbidly obese patients were included in this prospective study. They were 358 women and 97 men, with a mean age of 41 years and a mean body mass index of 43 kg/m2. In all an endoscopic evaluation was performed 1 month after surgery, which was repeated in 315 patients (71.6%) 17 months after surgery, independent of the presence or not of symptoms. Anastomotic diameter was measured and strictures were classified as: (a) mild, with a diameter of 7 to 9 mm, (b) moderate with a diameter of 5 to 6 mm, and (c) difficult or critical with a diameter equal or less to 4 mm. Two methods of dilatation were employed: the endoscope itself or Savary-Gilliard dilators. Patients were submitted to laparotomic resectional gastric bypass in whom a circular stapler 25 was employed for gastrojejunal anastomosis or to laparoscopic gastric bypass, in whom hand-sewn one layer continuous suture was employed.

RESULTS

One month after surgery, 23% of patients after open gastric bypass employing circular stapler 25 presented anastomotic stricture, being 22% of them critical. After laparoscopic gastric bypass employing hand-sewn anastomosis, 36% of the patients presented strictures, being critical 10% (p>0.17). Patients with mild or moderate strictures needed one or two dilatations. Patients with critical strictures needed three to five dilatations. There were no complications associated to dilatation. Moderate and severe strictures were symptomatic; however 29% of patients with mild strictures were asymptomatic. Endoscopy was repeated in 71% of the whole group 17 months after surgery, demonstrating normal anastomosis in all.

CONCLUSIONS

Stricture at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Near 60% present a mild stricture (with a diameter between 7 and 9 mm), being 28% asymptomatic. This complication is easily treated by endoscopic procedure if it is diagnosed early (3 to 4 weeks) after surgery. Routine endoscopy 1 month after surgery is the only objective scientific way to determine the real true incidence of this complication.

Laparoscopic Roux-en-Y gastric bypass for morbidly obese Chinese patients: learning curve, advocacy and complications

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) involves a combination of both restrictive and mal-absorptive mechanisms and has become the procedure of choice for patients with morbid obesity in Western countries. However, its efficacy remains uncertain in Asian populations. We report our pilot experience with LRYGB in a Chinese population.

METHODS

Between August 2005 and February 2007, 100 morbidly obese patients received LRYGB. We evaluated the learning curve for the operation, its efficacy in weight reduction, and its postoperative complications.

RESULTS

Surgical time reached a plateau after about 50 cases, decreasing from 216 min for the initial 50 patients to 105 min for the final 50. The conversion rate from laparoscopic to open surgery was 2%. The mean percent body mass index loss was 33.9% after 12 months. Twenty-four complications occurred in 18 patients, but most resolved with conservative treatment without mortality. Patients with advanced age (P = 0.04) or hypertension (P = 0.03) were at increased risk for complications leading to prolonged surgical times and hospital stays. The complication rate declined as technical expertise increased.

CONCLUSION

In Chinese patients with morbid obesity, LRYGB is promising procedure because of its acceptable learning curve, good efficacy, and low complication rate.

Endoclip Closure of Jejunal Perforation after Balloon Dilatation

Endoscopy is commonly used in patients undergoing Roux-en-Y gastric bypass (RYGBP) for diagnosis and intervention. Stomal stricture at the gastrojejunostomy occurs in approximately 3% to 17% of patients after laparoscopic RYGBP. The incidence of iatrogenic perforation during stomal balloon dilatation is reported to be 3% to 12% among these patients. Surgery has typically been required for iatrogenic perforation. With the availability of the endoclip, endoscopists are able to manage iatrogenic perforation non-operatively. We report a patient who had jejunal perforation during balloon dilatation after RYBGP, who was successfully closed with endoclip applications and managed non-operatively.