Endotherapy in Unusual Bariatric Surgical Complications (with Videos)

Laparoscopic Roux-en-Y gastric bypass complicated by a mesocolic jejunal stricture successfully treated with endoscopic TTS balloon dilation

Even though Roux-en-Y gastric bypass is the most commonly performed bariatric surgery in the United States, it is not without post surgical complications. The development of a mesocolic jejunal stricture after a laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a rare complication. We present a patient who manifested, at 5 weeks post-LRYGBP, symptoms of nausea, vomiting, and an inability to tolerate an oral diet. The patient was found to have a stricture at the efferent Roux limb consistent with a mesocolic stricture which was successfully resolved with through the scope (TTS) balloon dilatation. There was no apparent cause of the patient's stenosis with no evidence of an anastomotic breakdown or major inflammatory process. The patient presented for follow-up after her dilatation was noted to have complete resolution of her symptoms and continued to lose weight. This is the first known case of a mesocolic jejunal stricture successfully treated with TTS balloon dilation.

Management of transmesenteric tunnel jejunal strictures with endoscopic dilation by using achalasia balloons (with videos)

BACKGROUND

Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Transmesenteric tunnel (TMT) or mesocolic jejunal stricture is an unusual postoperative complication that requires another operation. We hypothesize that endoscopic dilation by using achalasia dilatation balloons can be used to treat some TMT jejunal strictures.

PATIENTS

This study involved 6 consecutive cases of TMT stricture.

INTERVENTION

The TMT strictures were dilated by using achalasia balloons (30-40 mm) under fluoroscopic and endoscopic guidance.

RESULTS

With endotherapy, 4 patients with late onset of symptoms (>3 weeks after Roux-en-Y gastric bypass) have not required another operation to date, with a follow-up of at least 5 to 12 months. Two patients with early onset of symptoms (<3 weeks after surgery) required operations, and 1 of these patients (symptoms onset <7 days after surgery) developed jejunal perforation within the stricture during dilation due to underlying jejunal ischemia within the stricture.

LIMITATIONS

Small case number and limited follow-up period.

CONCLUSION

Endoscopic dilation by using achalasia balloons can be used to treat some TMT jejunal strictures without another operation. Surgery should be considered in patients with early onset of obstructive symptoms and/or with jejunal ischemia within the stricture.

Retrograde endoscopic cystgastrostomy for pancreatic pseudocyst drainage after a Prior Roux-en-Y gastric bypass

A 47-year-old woman with a history of Roux-en-Y gastric bypass developed a pancreatic pseudocyst after an episode of acute necrotizing pancreatitis. She presented with intractable abdominal pain and weight loss. Computed tomography scan revealed an enlarging pancreatic fluid collection abutting the gastric antrum. The patient underwent exploratory laparotomy, at which a Whipple procedure was aborted due to severe fibrosis and necrosis of her pancreas. Retrograde peroral endoscopic pancreatic pseudocyst drainage was successfully performed through the defunctionalized stomach.