Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis

3dct Conduit and Oesophageal Metrics, a Valuable Method to Diagnose Post Sleeve Gastrectomy Abnormalities

PURPOSE

Reflux after laparoscopic sleeve gastrectomy (LSG) may result from anatomical and functional anomalies in the gastric conduit. Three-dimensional CT scans (3DCT) offer a comprehensive view of gastric anatomy. This study aims to establish specific measurements associated with sleeve abnormalities to standardise the reporting of 3DCT which may help in management of LSG complications.

MATERIALS AND METHODS

This retrospective study analysed 64 post-LSG patients who underwent gastric 3DCT. Data included clinical demographics, pre-LSG BMI, BMI at 3DCT, and the duration between surgery and examination. Symptomatology prompts the scan and other concurrent investigations. Various 3DCT measurements were taken, including angularis angle (AA), surface area (ASA), conduit length (CL), proximal maximal surface area (PMSA), and distal maximal surface area (DMSA) of the gastric conduit. Patients were categorised based on endoscopy findings and symptomatology. Outcomes post-revisional surgery were assessed and analysed.

RESULTS

20.3% were male. Pre-LSG BMI and BMI at 3DCT were 45.57 (± 8.3) and 36.3 (± 8.7), respectively. Mean surgery-to-scan period was 6.2 years. 71.8% of patients presented with reflux, regurgitation, or dysphagia, whilst the remainder primarily exhibited weight regain. Patients with endoscopic evidence of stenosis/reflux demonstrated significantly lower gastric volume, ASA, and DMSA (p = 0.002 and p = 0.007, respectively). Oesophageal diameter above the conduit and an ASA to DMSA ratio ≤ 0.5 were negatively associated with AA (p = 0.008 and p = 0.08, respectively). Patients with improved outcomes after revisional bypass and gastrogastrostomy displayed a negative correlation with ASA and positive correlation with the ASA to PMSA ratio (≤ 0.5).

CONCLUSION

3DCT measurements have a potential role in defining post-LSG stenosis and predicting outcomes of revisional surgery. Patients with anatomic abnormalities that are shown on CT appear to improve with anatomic correction.

Endoscopic management of complications after sleeve gastrectomy: a narrative review

Sleeve gastrectomy (SG) has become the most widely performed bariatric procedure globally due to its technical simplicity and proven efficacy. However, complications following SG, including bleeding, leakage, fistulas, stenosis, gastroesophageal reflux disease (GERD), and hiatal hernia (HH), remain a significant concern. Endoscopic interventions have emerged as valuable minimally invasive alternatives to traditional surgical approaches for managing these complications. This review aims to provide a comprehensive overview of the endoscopic management strategies available for addressing the various complications encountered after SG, emphasizing their critical role in optimizing patient outcomes.

Emerging indications for third space endoscopy

This chapter will explore the recent advancements and innovations in the field of third space endoscopy. The traditional principles of per-oral endoscopic myotomy and endoscopic submucosal dissection have been applied to offer solutions to traditionally difficult to manage problems including esophageal diverticula, post-fundoplication dysphagia, post-sleeve gastrectomy stricture, bariatric procedure and Hirschsprung disease. Typically, these problems were managed surgically with potentially high rates of morbidity and mortality; however, the principles of third space endoscopy offer a safer and less invasive option for management. All of these applications of third space endoscopy are less than a decade old with some emerging in the last 1-2 years. In this chapter, we will explore the pathophysiology of these diseases and how third space endoscopy can offer a solution. We will also review the relevant literature along with the safety and effectiveness of the proposed innovations.

Use of Impedance Planimetry in the Diagnosis of Gastric Sleeve Stenosis: The Establishment of New Benchmark Values

INTRODUCTION

Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy for which objective diagnostic criteria are lacking. Impedance planimetry measurements show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.

METHODS

This was a retrospective analysis of upper endoscopies performed with impedance planimetry for suspected GSS. A bariatric endoscopist, blind to impedance planimetry measurements, assessed gastric sleeve anatomy and graded GSS severity. Impedance planimetry of diameter and distensibility index (DI) were obtained using 3 different balloon volumes (30, 40, and 50 mL).

RESULTS

A total of 110 upper endoscopies were included. Distribution of GSS was graded as none, mild, moderate, and severe in 19 (17%), 27 (25%), 34 (31%), and 30 (27%) procedures, respectively. In normal gastric sleeve anatomy, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. In severe GSS, mean diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±2.4) to 7.7 (±2.4), respectively. When stratified by severity, impedance planimetry measurements of diameter and DI were significantly lower with each subsequent increase in GSS grade regardless of balloon fill volumes ( P ≤ 0.001).

DISCUSSION

Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. A diameter ≥20 mm and a DI ≥15 mm 2 /mm Hg, as measured by impedance planimetry, are predictive of normal gastric sleeve anatomy. This study provides new benchmark values for the diagnosis and severity of GSS.

The Efficacy and Safety of Endoscopic Balloon Dilatation in the Treatment of Functional Post-Sleeve-Gastrectomy Stenosis

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients' clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

Piriform Fossa Injury during Calibration Tube Insertion in Laparoscopic Sleeve Gastrectomy

Piriform fossa and/or esophageal injuries caused by calibration tubes are relatively rare and remain unelucidated. Herein, we report the case of a 36-year-old woman with morbid obesity, sleep apnea, and menstrual abnormalities who was scheduled to undergo laparoscopic sleeve gastrectomy (LSG). We inserted a 36-Fr Nelaton catheter made of natural rubber as a calibration tube during the surgery. However, excessive resistance was observed. We confirmed a submucosal layer detachment approximately 5 cm from the left piriform fossa to the esophagus using intraoperative endoscopy. Additionally, LSG was performed using an endoscope as the guiding calibration tube. We inserted a nasogastric tube under endoscopy with a guidewire before completing the surgery, hoping for a guiding effect on the saliva flow. After 17 months, the patient had successfully lost weight postoperatively without complaints of neck pain or discomfort during swallowing. Therefore, in cases where the damage is limited to the submucosal layer, as in this case, conservative therapy should be considered; this is similar to the concept of endoscopic submucosal dissection not requiring suture closure. This case highlights the risk of iatrogenic injuries to the piriform fossa and/or esophagus during LSG and the importance of careful calibration tube insertion to prevent them.

Treatments for Staple Line Leakage after Laparoscopic Sleeve Gastrectomy

The number of laparoscopic sleeve gastrectomies (LSGs) performed in patients with obesity who are eligible for bariatric and metabolic surgery is currently much lower in Japan than in other countries. Considering the large number of potential patients with obesity and type 2 diabetes and the unique Japanese national health insurance system that guarantees fair healthcare delivery, there is room to increase the number of LSGs in Japan in the near future. However, strict health insurance regulations may limit access to mandatory devices needed to treat postoperative complications, such as staple line leakage, which can cause severe morbidity and even mortality. Therefore, understanding the pathogenesis and treatment options for this complication is crucial. This article examined the current situation in Japan and its impact on staple line leakage management, including the role of endoscopic treatment in reducing reoperation. The authors suggest increasing education and collaboration between healthcare professionals to optimize management and improve patient outcomes.

Endoscopic severity of gastric sleeve stenosis can be quantified using impedance planimetry

BACKGROUND

Gastric sleeve stenosis (GSS) is an adverse event following sleeve gastrectomy for which objective tools are needed for diagnosis and treatment. Endoscopic treatment with serial pneumatic balloon dilation may relieve symptoms and prevent the need for conversion to Roux-en-Y gastric bypass. Endoluminal functional impedance planimetry (EndoFLIP) is an endoscopic tool that measures luminal diameter and distensibility indices (DI) and could be used to characterize severity of GSS.

METHODS

This was a retrospective analysis of a prospective database of patients referred for symptoms suggestive of GSS. Severity was determined at each endoscopy by a bariatric endoscopist blinded to EndoFLIP measurements. Successive pneumatic balloon dilations were performed until symptoms resolved; failure was defined as referral for conversion. EndoFLIP measurements of stenosis diameter and DI were obtained pre- and post-dilation. Primary outcomes were pre- and post-dilation luminal diameter and DI of GSS. Secondary outcomes were endoscopic severity of GSS, patient characteristics, and need for surgical revision.

RESULTS

26 patients were included; 23 (85%) were female. Mean age was 45.3 (± 9.9) years. Mean number of dilations was 2.4 (± 1.3) and 10 (38%) patients were referred for conversion. Mild, moderate, and severe GSS was found in 10 (38%), 6 (23%), and 10 (38%) patients, respectively. Moderate and severe GSS underwent more dilations (2.5 ± 1.0 and 3.2 ± 1.6) than mild GSS (1.8 ± 0.8) and were more likely to be referred for conversion. Both pre- and post-dilation diameters were significantly larger in mild versus moderate or severe GSS. Additionally, pre- and post-dilation DI at 30 ml were significantly higher for mild compared to moderate and severe GSS.

DISCUSSION

EndoFLIP measurements correlate well with endoscopic assessment of GSS. While more data are needed to determine ideal balloon size and threshold measurements, our results suggest EndoFLIP may help expedite diagnosis and treatment of GSS.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Diagnosis and Management of Postoperative Complications After Sleeve Gastrectomy

Sleeve gastrectomy (SG) has demonstrated excellent outcomes in terms of weight loss and resolution of obesity-related comorbidities as a single procedure. It has gained rapidly increasing popularity among bariatric surgeons and patients over the last two decades. This is due to its relative ease of use and less frequent morbidities related to the procedure. Even though the overall complication rate after SG is reported to be lower than conventional Roux-en-Y gastric bypass or biliopancreatic diversion, it still affects 1-10% of the patients undergoing SG, which is not negligible. Early postoperative complications that can occur within 30 days after SG include hemorrhage, leakage, sleeve stenosis, and reflux. Thromboembolic events are rare but can occur after surgery. Here, we review the incidence, diagnosis, and management of these early postoperative complications.

Pneumatic Balloon Dilation of Gastric Sleeve Stenosis Is Not Associated with Weight Regain

BACKGROUND

Gastric sleeve stenosis (GSS) occurs in up to 4% of patients after laparoscopic sleeve gastrectomy (LSG). Typical symptoms include reflux, abdominal pain, dysphagia, and regurgitation. Serial pneumatic balloon dilation (PBD) is a successful treatment in many cases obviating the need for revisional surgery, but the potential for weight regain is unknown. The aim of the current study was to assess weight trends following serial pneumatic dilation for GSS.

METHODS

Retrospective analysis of a prospectively maintained database of patients undergoing serial PBD for GSS at one institution. Primary outcome was change in BMI before and after serial PBD. Secondary outcomes included complication rates and need for revisional surgery. Sub-group analyses were performed to determine the relationship of patient and procedural factors to BMI after PBD.

RESULTS

Forty-four patients met inclusion criteria, 34 (84.1%) women. Mean age was 46.7 (SD 11.9). Mean pre-sleeve BMI was 47.8 (SD 9.2), and mean BMI prior to first dilation was 34.2 (SD 6.8). Median follow-up was 395 days (range 48-571). Mean BMI at time of last follow up was 33.7 (SD 6.7). There was no statistical difference in BMI pre- or post-PBD (p 0.980). The lowest 10th and highest 90th BMI percentile trended toward a higher and lower BMI after PBD, respectively, though not significant.

DISCUSSION

As the prevalence of sleeve gastrectomy continues to rise, an increasing number of patients will require treatment for GSS. Stenosis is effectively treated with serial PBD in most patients without any impact on weight gain, making this an effective and appealing option for many patients.

Gastric per-oral endoscopic myotomy (G-POEM) for the treatment of gastric sleeve stenosis: a feasibility and safety study

BACKGROUND

Traditional endoscopic treatments have limited success in gastric sleeve stenosis (GSS). Gastric peroral endoscopic myotomy (G-POEM) could conceivably obliterate the twist/angulation that causes GSS through a tunneled stricturotomy. We report early outcomes of G-POEM for GSS treatment.

METHODS

We retrospectively reviewed all patients with GSS treated with G-POEM at our center. The primary end point was clinical success, defined as symptom improvement with resumption of adequate oral intake, without requiring further intervention.

RESULTS

13 patients (mean age 43 ± 10.9 years; 12 female) underwent G-POEM for predominantly helical (11/13, 85 %) GSS. Three (23 %) had concurrent sleeve leak and 10 (77 %) had prior GSS treatment. Two intraoperative complications occurred, with no deviation to the procedure; no major complications occurred. At median follow-up of 175 (interquartile range [IQR] 119-260) days, clinical success was achieved in 10 patients (77 %). Median Gastroparesis Cardinal Symptom Index score in responders decreased from 2.06 (IQR 1.5-2.8) to 0.39 (IQR 0.2-0.5). Three patients (23 %) required surgical revision.

CONCLUSIONS

G-POEM was feasible and safe, and may provide an alternative option for those averse to undergoing surgical revision for treatment of GSS.

Quantifying Healthcare Utilization and Delay in the Treatment of Gastric Stenosis Following Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric procedure performed. The incidence of gastric sleeve stenosis (GSS) is up to 4%, with a rising prevalence given increasing popularity of this surgery. GSS is best treated with pneumatic balloon dilation (PBD), but the diagnosis is not always straightforward, oftentimes leading to an extensive diagnostic workup. The aims of the current study were to quantify delay to treatment and overall healthcare utilization during this delay in patients with GSS following SG.

METHODS

This was a retrospective review of a prospectively collected database including patients with SG diagnosed with GSS between October 2017 and September 2020. The primary outcome was time between symptom development and treatment with PBD. Secondary outcomes included total healthcare utilization as reflected by the number and charges of imaging and emergency room (ER) visits.

RESULTS

Forty-five patients were included in the analysis; 37 (82%) were female. The mean (± SD) time to treatment was 755 (± 713) days. The probability of receiving treatment at 1, 2, and 3 years was 37%, 62%, and 76%, respectively. The mean (± SD) abdominal CT scans, radiographs, and UGIS between symptoms and PBD were 1.3 ± 2.0, 1.2 ± 1.6, and 1.2 ± 1.0, respectively. The mean number of ER visits was 1.9 ± 2.5 (range 0-8). The average number of diagnostic non-therapeutic upper endoscopies was 1.6 ± 1.5. The mean (± SD) total charges were $16,473 ± 15,173.

CONCLUSION

Patients who develop GSS following SG experience significant delay in diagnosis and management, reflected by multiple imaging studies, emergency department visits, and non-therapeutic procedures.

Endoscopic Management of Sleeve Stenosis

PURPOSE

Sleeve gastrectomy is one of the most popular bariatric procedures performed. A complication of this surgery is sleeve stenosis, causing significant morbidity and the need for corrective intervention. Endoscopic treatment using pneumatic dilation has evolved as an effective, and minimally invasive, technique to successfully treat this complication. Here we report our experience with endoscopic management of sleeve stenosis at a tertiary bariatric center.

MATERIAL AND METHODS

We identified all patients that underwent endoscopic management of sleeve stenosis at a tertiary bariatric center from 2010. We reviewed patient demographics, operative data, interval to endoscopic treatment, and outcomes of pneumatic dilations.

RESULTS

Sixty seven patients underwent 130 endoscopic dilations. The majority of these patients were female (71%), and at the time of sleeve gastrectomy average age was 43.3 years (range 18-68 years) and average BMI was 41.5 kg/m² (range 31-63 kg/m²). The time interval to first endoscopic procedure was 7.2 months (range 0.75-53 months), with an average of 2 procedures per patient. During the follow-up period, the success rate of endoscopic dilatation was 76.1%, while the remaining 16 patients underwent conversion to gastric bypass. Two patients underwent emergency conversion to gastric bypass for sleeve perforation during the procedure (1.5%). There was a modest weight gain of 3 kg (4.2% total body weight) after sleeve dilatation.

CONCLUSIONS

Endoscopic management of sleeve stenosis is safe and effective, with a success rate of over 75%. During endoscopic management, there was a 1.5% risk of sleeve perforation requiring emergency surgery. Mild weight regain occurred following endoscopic sleeve dilation.

Obstruction after Sleeve Gastrectomy, Prevalence, and Interventions: a Cohort Study of 9,726 Patients with Data from the Scandinavian Obesity Surgery Registry (SOReg)

Background

Sleeve gastrectomy (SG) is the most common bariatric procedure worldwide. Obstructive symptoms, together with leaks, are among the most serious postoperative complications. This study aimed to investigate the incidence of symptomatic obstruction after SG in Sweden and to explore risk factors, treatment strategies, and outcome.

Methods

A retrospective analysis of prospectively collected data from the Scandinavian Obesity Surgery Registry (SOReg) of patients undergoing SG and developed obstruction symptoms within the first postoperative year was performed. For patients who had undergone any re-intervention, such as endoscopic dilatation or remedial surgery, medical charts were reviewed.

Results

From 2007 to 2018, a total of 9,726 SG were performed, and 59 (0.6%) of them developed postoperative obstruction. Intolerance of solid food was the most common symptom associated with obstruction (80%). Sixty-one percent of the patients had obstruction at the level of incisura angularis. Longer operative time, higher rate of perioperative complications, longer hospital stay, and oversewing the staple line were associated with an increased risk of obstruction. Endoscopic balloon dilatation was performed in 59% of patients (n=35) and successful in 18 patients (51%). Twenty-one patients (36%) underwent surgical conversion to Roux-en-Y gastric bypass (RYGB). After revisional surgery, 11 (52%) reported complete relief of symptoms.

Conclusions

Obstruction was rare (0.6%) and most often located at the incisura angularis. Obstruction was associated with longer operative time, perioperative complications, oversewing of the staple line, and longer hospital stay. Endoscopic dilatation or surgical conversion to RYGB frequently alleviates symptoms, but despite treatment, almost 50% reported residual symptoms.

Graphical abstract

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Laparoscopic Vertical Sleeve Gastrectomy

Bariatric surgery has emerged as the most effective means of achieving weight loss. Obesity surgery is a quickly expanding field. Laparoscopic vertical sleeve gastrectomy is a great option for patients because it is simple, exceedingly safe, has a fairly defined postoperative complication profile, and is as effective as more complex bariatric surgery options. Specific consideration of patients' comorbidities, assessment of surgeon's skill, and knowledge of preoperative, perioperative, and postoperative course is a must for all surgeons who wish to perform this procedure. If properly used, vertical sleeve gastrectomy is a powerful tool in combating obesity and its deleterious effects.

Gastric Per-Oral Endoscopic Myotomy for Treatment of Chronic Proximal Staple Line Leak Precipitated by Downstream Stenosis

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric surgery. Although considered a safe procedure, adverse events such as staple line leak in the context of sleeve stenosis can result in significant patient morbidity and health economic burden. Correction of the downstream stenosis is mandatory for closure of the staple line leak. Conventional endoscopic therapies offer high initial success rates, though ultimately a significant proportion proceed to revision surgery. Gastric per-oral endoscopic myotomy (G-POEM) is a novel, minimally invasive procedure which allows for a full-thickness myotomy of the stenosed segment, potentially conferring similar anatomical correction to surgical seromyotomy. We present a case of recalcitrant chronic proximal staple line leak in the context of a downstream gastric stenosis managed by G-POEM.

Implications of Technical Factors in Development of Early Sleeve Stenosis After Laparoscopic Sleeve Gastrectomy: an Analysis Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Sleeve stenosis (SS) is a rare complication of LSG and is associated with significant morbidity and economic burden. The objective of this study was to determine the prevalence and impact of early SS and identify technical factors which may predict its development.

MATERIALS AND METHODS

Data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018. Patients undergoing primary LSG were included, while patients undergoing revisional bariatric surgery were excluded. A multivariable logistic regression analysis was performed to identify technical factors associated with SS.

RESULTS

A total of 389,839 patients (79.4% female) were included with a mean age of 44.2 ± 12.0 years and mean body mass index of 45.1 ± 7.8 kg/m². SS was rare, occurring in only 0.09% (n=345) of patients within 30 days of the operation. Following multivariable analysis, technical factors associated with early SS included prolonged operative time > 60 min (OR 1.32, 95% CI 1.17-1.48, p < 0.001) and a shorter PD (OR 0.864, 95% CI 0.784-0.951, p=0.003). For every 1-cm increase in PD, the odds of SS decreased by 13.6%.

CONCLUSION

Overall, early SS is a rare complication, affecting only 0.09% of patients undergoing primary LSG. Technical factors associated with 30-day SS included PD and operative time. Though current guidelines suggest a PD as short as 2 cm, our findings suggest this may be associated with an increased risk of early postoperative SS.

Endoscopic Dilation of Post-Sleeve Gastrectomy Stenosis: Long-Term Efficacy and Safety Results

INTRODUCTION

Post-sleeve gastrectomy (SG) stenoses occur in about 5% of cases. Hydrostatic dilation (HD) and pneumatic dilation (PD) have been proposed as treatments, but efficacy data remain scarce. Objective is to describe long-term efficacy and safety of HD and PD.

METHODS

This retrospective study in a referral endoscopy center included patients with symptomatic post-SG stenosis treated with endoscopic balloon dilation (EBD). Stenosis was defined as "organic" if luminal narrowing was evident, "functional" for a deformation, or "combined." Endoscopic treatment consisted of ≥ 1 HD (15-20 mm) and/or ≥ 1 PD (30-35 mm). Initial success was defined as improvement of stenosis-related symptoms at 1 month and long-term success as persistence of improvement at last follow-up.

RESULTS

Forty-four patients (73% women; mean age 45.5 ± 11 years; mean follow-up 26 ± 23 months) underwent EBD between 2013 and 2019. HD and PD were used in 15 (34%) and 29 (66%) patients, respectively, (mean dilation number: 1.8 ± 1.1). Post-SG stenoses were considered organic in 10 (23%), functional in 21 (48%), and combined in 13 (29%) patients. Initial success was achieved in 42 (96%) patients, while 35 (80%) patients had no symptom recurrence at last follow-up. Perforation occurred in one patient. HD was more frequently used in organic stenoses (8/10), while PD in functional and combined stenoses (18/21 and 9/13, respectively; p < 0.001). Rates of success did not differ by type of stenosis.

CONCLUSION

Endoscopic dilation is an effective treatment for post-SG stenoses, providing long-term symptom relief. PD should be preferred in cases of functional stenoses, and HD used for organic stenoses.

Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study

BACKGROUND AND AIMS

Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort.

METHODS

Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months.

RESULTS

Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation.

CONCLUSIONS

R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.

Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos)

BACKGROUND AND AIMS

As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type.

METHODS

The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized.

RESULTS

Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving.

CONCLUSIONS

Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.

Gastric Stenosis After Sleeve Gastrectomy: an Algorithm for Management

BACKGROUND

Gastric stenosis (GS) is a well-recognized complication after sleeve gastrectomy (SG) with a negative impact on patients' nutritional status and quality of life. There is no consensus on a validated, comprehensive management algorithm for GS. This study evaluates treatment modalities and proposes a management algorithm for obstructive gastric symptoms (OGSs) after SG.

METHODS

This is a retrospective cohort study of patients with GS after SG between January 2013 and January 2019. Patients with concomitant GS and staple-line leak were excluded. The primary outcome was the clinical response to treatment.

RESULTS

Forty-nine patients presented with OGSs. One patient underwent urgent surgical treatment for acute migration of cardia. Of 42 patients who had evident GS, pneumatic balloon dilatation (PBD) achieved clinical success in 28 (66.7%) patients. Six patients were diagnosed with indolent GS, and four of them improved after empirical PBD. The mean interval from index surgery to PBD was 5.3 (± 4.2) months. Longer duration of PBD session was associated with better clinical outcomes (5.8 ± 3.7 vs. 3.2 ± 1.7 min) (P = 0.017). After failed PBD, endoscopic stenting (n = 2) and revisional surgery (n = 7) were performed with clinical success in all patients.

CONCLUSION

PBD using achalasia balloon is the mainstay of treatment with good clinical outcomes. The utility of endoscopic stenting for GS should be different from its use for leakage in aspects of dwelling time and required endoscopic expertise. RYGB is the gold standard revisional procedure due to the high success rate and technical familiarity. Controversial aspects of management require future prospective comparative studies.

Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery

Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.

Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Gastric stenosis is a rare but potentially serious adverse event after sleeve gastrectomy. Despite current suboptimal treatments, endoscopic balloon dilatation (EBD) has emerged as a safe and efficacious approach. The purpose of this study is to assess the overall success of EBD for sleeve gastrectomy stenosis (SGS) as first-line therapy.

METHODS

MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane Database were searched from inception to July 2018. The primary outcome was defined as overall success rate of clinical resolution of SGS obstructive symptoms with EBD, expressed as pooled event rate and 95% confidence interval (CI). The secondary predefined outcomes include EBD success rates for SGS in the proximal (cardia) location or mid-distal location (antrum/incisura), in early SGS (up to 3 months after laparoscopic sleeve gastrectomy), and late SGS (3 months or longer after laparoscopic sleeve gastrectomy) and success rate of cases requiring stents or salvage surgery.

RESULTS

Eighteen studies encompassing 426 patients were analyzed. The average age and body mass index were 41.7 years and 40.1 kg/m², respectively, and the average number of dilations for all cases was 1.8 per person. Overall EBD success rate was 76% (95% CI, .67-.86). EBD success rate in the proximal SGS was 90% (95% CI, 63%-98%), distal SGS was 70% (95% CI, 47%-86%), early SGS within 3 months was 59% (95% CI, 34%-79%), and late SGS after 3 months was 61% (95% CI, 41%-78%). Seventeen percent of patients underwent secondary salvage surgery, with a success rate of 91% (95% CI, 80%-96%).

CONCLUSIONS

Endoscopic balloon dilation appears to be a safe and effective minimally invasive alternative to surgical revision and should be used as first-line therapy for SGS.

Gastric Per-Oral Endoscopic Myotomy (G-POEM) for the Treatment of Gastric Stenosis Post-Laparoscopic Sleeve Gastrectomy (LSG)

Laparoscopic sleeve gastrectomy (LSG) has become the most common form of bariatric surgery performed worldwide. However, it is associated with potentially debilitating adverse events such as post-operative stenosis. Finding effective and minimally invasive treatments for such complications is of paramount importance. Gastric per-oral endoscopic myotomy (G-POEM) is a novel procedure developed over the past decade to treat conditions that delay gastric emptying. We present a case demonstrating the use of G-POEM in the successful endoscopic management of post-LSG gastric stenosis.

Is pneumatic balloon dilation safe and effective primary modality of treatment for post-sleeve gastrectomy strictures? A retrospective study

BACKGROUND

The optimal treatment of sleeve strictures has not been agreed upon at the current time. At our institution, we began using pneumatic balloon dilation to help resolve these obstructions in 2010. Herein we report our experience with pneumatic balloon dilation for the treatment of sleeve strictures.

METHODS

From Jan 2010 to Dec 2016 we retrospectively reviewed our prospectively kept database for patients who developed a Laparoscopic Sleeve Gastrectomy (LSG) stricture within 90 days of surgery. If the stricture was found, then we dilated all our patients initially at 30 mm at 10 PSI for 10-20 min (14.5 min average) and increased the balloon size (30-40 mm) and duration (10-30 min) in subsequent sessions if the first session was unsuccessful.

RESULTS

The review found that 1756 patients underwent either LSG or the first step of a Laparoscopic Duodenal Switch (LDS) (1409 LSG & 356 LDS). Of the 1756 patient 33 patients (24 underwent LSG, and 9 underwent LDS) developed a stricture as a complication of LSG. The average age of the patients was 46.4 (±9.6) years, and the average BMI was 43.7 (±6.4). The most common location for stricture was mid-body of the sleeve (54.5%). The average time from the primary surgery to diagnosis and first pneumatic dilation was 5.6 months (± 6.8) and 5.9 months (± 6.6) respectively. We successfully used pneumatic dilation in 31 (93.9%) of these patients to relieve the stricture.

CONCLUSION

We conclude that pneumatic dilation is an effective procedure in patients with post sleeve gastrectomy stricture.