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Dell’Anna G, Fanizza J, Mandarino FV, Barchi A, Fasulo E, Vespa E, Fanti L, Azzolini F, Battaglia S, Puccetti F, Cossu A, Elmore U, Facciorusso A, Dell’Anna A, Fuccio L, Bruni A, Massironi S, Annese V, Malesci A, Donatelli G, Rosati R, Danese S. The Endoscopic Management of Anastomotic Strictures After Esophagogastric Surgery: A Comprehensive Review of Emerging Approaches Beyond Endoscopic Dilation. J Pers Med 2025; 15:111. [PMID: 40137427 PMCID: PMC11943101 DOI: 10.3390/jpm15030111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/09/2025] [Accepted: 03/12/2025] [Indexed: 03/27/2025] Open
Abstract
Anastomotic strictures are a common complication following esophagogastric surgery, with prevalence varying depending on the type of surgery and anatomical site. These strictures can lead to debilitating symptoms such as dysphagia, pain, and malabsorption, significantly impacting patients' quality of life. Endoscopic treatment of anastomotic strictures has established a role as the first-line strategy in this setting instead of revision surgery, offering benefits in terms of lower morbidity. Various endoscopic methods are available for anastomotic stricture management, including balloon dilation, stent placement, the new lumen-apposing metal stent, and endoscopic incision techniques. However, there is currently no strong evidence and established guidelines for the optimal treatment strategy. Available data suggest that endoscopic treatments, when performed in tertiary referral centers, can provide favorable outcomes in terms of symptom relief and reduced need for rescue surgical intervention. Nonetheless, challenges remain regarding the management of recurrent strictures and procedural complications, underscoring the need for a personalized, multidisciplinary approach to optimize clinical outcomes. This review aims to provide an updated overview of endoscopic techniques and available evidence with a focus on the most recent technologies, supporting clinicians in effectively managing anastomotic strictures in complex clinical settings.
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Affiliation(s)
- Giuseppe Dell’Anna
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
| | - Alberto Barchi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
| | - Ernesto Fasulo
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
| | - Edoardo Vespa
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
| | - Lorella Fanti
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
| | - Francesco Azzolini
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
| | - Silvia Battaglia
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (S.B.); (F.P.); (A.C.)
| | - Francesco Puccetti
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (S.B.); (F.P.); (A.C.)
| | - Andrea Cossu
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (S.B.); (F.P.); (A.C.)
| | - Ugo Elmore
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (S.B.); (F.P.); (A.C.)
| | - Antonio Facciorusso
- Faculty of Medicine and Surgery, University of Salento, Piazza Tancredi 7, 73100 Lecce, Italy;
| | - Armando Dell’Anna
- Digestive Endoscopy Unit, “Vito Fazzi” Hospital, Piazza Filippo Muratore 5, 73100 Lecce, Italy;
| | - Lorenzo Fuccio
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (L.F.); (A.B.)
| | - Angelo Bruni
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (L.F.); (A.B.)
| | - Sara Massironi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
| | - Alberto Malesci
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
| | - Gianfranco Donatelli
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Sant, 75013 Paris, France;
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80138 Naples, Italy
| | - Riccardo Rosati
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (S.B.); (F.P.); (A.C.)
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (J.F.); (F.V.M.); (A.B.); (E.F.); (E.V.); (L.F.); (F.A.); (S.M.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy; (U.E.); (R.R.)
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Agrawal R, Cohen EM, Adekolu AA, Maan S, Haffar M, Chowdhry M, Thakkar S, Singh S. Creation of new anastomosis for management of obstructive symptoms related to gastrojejunal anastomosis in patients who undergo gastric bypass: a case series. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2025; 10:44-47. [PMID: 39925406 PMCID: PMC11806424 DOI: 10.1016/j.vgie.2024.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
Abstract
Background and Aims Roux-en-Y gastric bypass (RYGB) is associated with gastrojejunal (GJ) strictures in up to 20% of patients. Surgical revision of the GJ anastomosis is technically challenging and carries significant morbidity, making endoscopic therapies such as endoscopic balloon dilation (EBD) and stent placement the preferred approach. In addition, the angulation of GJ anastomosis relative to the Roux limb can cause obstructive symptoms, which are less amenable to EBD or stent placement. In patients with refractory strictures and/or angulation, we evaluate the safety and feasibility of a new anastomosis EUS-guided gastroenterostomy as an alternative to surgical revision. Methods In patients with refractory GJ strictures and/or angulation, a new anastomosis EUS-guided gastroenterostomy between the gastric pouch and Roux limb is created. Results Our case series includes 6 patients with a history of RYGB referred for management of obstructive symptoms. Upper endoscopy revealed severe GJ stenosis in 2 patients, complete obliteration of GJ anastomosis in 1 patient, stenosis with angulation in 1 patient, and angulation only in 2 patients. Four patients underwent previous unsuccessful attempts at balloon dilation. Lumen-apposing metal stent (LAMS) placement was initially performed in 4 patients, resulting in resolution of symptoms. However, their symptoms recurred after LAMS removal. EUS-guided anastomosis between the gastric pouch and Roux limb was created successfully in all patients, with no major adverse events. One patient experienced LAMS migration after 54 days. Patients had complete resolution of symptoms after the new anastomosis anastomosis was created. Conclusions Our case series highlights the safety and feasibility of EUS-guided gastroenterostomy as an alternative to surgical revision in such patients. Large prospective studies with longer follow-up are needed to assess long-term outcomes of this intervention.
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Affiliation(s)
- Rohit Agrawal
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Ethan M Cohen
- Division of Internal Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Ayowumi A Adekolu
- Division of Internal Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Soban Maan
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Mouaz Haffar
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Monica Chowdhry
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Shyam Thakkar
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Shailendra Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
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Agrawal R, Maan S, Méndez A, Haffar M, Cohen EM, Adekolu AA, Krafft M, Thakkar S, Singh S. Safety and Efficacy of Lumen-Apposing Metal Stents for Management of Late Refractory Gastro-jejunal Strictures in Patients with Roux-en-Y Gastric Bypass (with Video). Dig Dis Sci 2025; 70:316-321. [PMID: 39487907 DOI: 10.1007/s10620-024-08707-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 10/20/2024] [Indexed: 11/04/2024]
Abstract
INTRODUCTION Roux-en-Y gastric bypass (RYGB) related late gastro-jejunal (GJ) strictures are often resistant to endoscopic balloon dilations. Lumen-apposing metal stents (LAMSs) have been used to treat benign strictures with favorable results. However, the data remains limited to justify LAMS use for management of post-RYGB late GJ strictures. We aim to evaluate the safety and efficacy of LAMS placement for the management of late GJ strictures that are refractory to balloon dilations in post-RYGB patients. METHODS This was a single center retrospective study that included all post-RYGB patients who underwent LAMS placement for management of late GJ strictures that had previously failed balloon dilations. Primary outcomes were technical and clinical success, and secondary outcomes were LAMS-related adverse events. RESULTS A total of 28 patients underwent LAMS placement for management of GJ strictures. Median age was 60.5 (IQR 50.5, 67.0) years and majority were females (27, 96.4%). Median interval between surgery and first diagnosis of GJ stricture was 13 years (IQR 7, 17.5). 20 × 10 mm LAMS was the most used stent (n = 24, 85.7%). The median procedure time was 23.5 (IQR 14.5, 32.0) minutes. Technical and short-term clinical success of LAMS placement was 100% (95% CI 87.9-100.0). Long-term success was achieved in 19 out of 25 patients (76.0%, 95% CI 56.6-88.5) that had over 3 months follow-up after LAMS removal. Stent migration was noted in 2 (7.1%) patients, and 1 (3.6%) patient each experienced pain and minor bleeding without the need for additional interventions. No patient in our cohort required surgical revision of GJ anastomosis. CONCLUSION Placement of LAMS is safe, technically feasible, and associated with a high clinical success rate in patients with late GJ strictures after RYGB who have failed prior balloon dilations. Placement of LAMS can be considered early in patients requiring multiple balloon dilations.
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Affiliation(s)
- Rohit Agrawal
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, 5th Floor Health Sciences Center, Suite 5500, PO Box 9161, Morgantown, WV, 26506, USA
| | - Soban Maan
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, 5th Floor Health Sciences Center, Suite 5500, PO Box 9161, Morgantown, WV, 26506, USA
| | - Alejandra Méndez
- Division of Internal Medicine, West Virginia University, Morgantown, WV, USA
| | - Mouaz Haffar
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, 5th Floor Health Sciences Center, Suite 5500, PO Box 9161, Morgantown, WV, 26506, USA
| | - Ethan M Cohen
- Division of Internal Medicine, West Virginia University, Morgantown, WV, USA
| | - Ayowumi A Adekolu
- Division of Internal Medicine, West Virginia University, Morgantown, WV, USA
| | - Matthew Krafft
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, 5th Floor Health Sciences Center, Suite 5500, PO Box 9161, Morgantown, WV, 26506, USA
| | - Shyam Thakkar
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, 5th Floor Health Sciences Center, Suite 5500, PO Box 9161, Morgantown, WV, 26506, USA
| | - Shailendra Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, 5th Floor Health Sciences Center, Suite 5500, PO Box 9161, Morgantown, WV, 26506, USA.
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Evans LA, Castillo-Larios R, Cornejo J, Elli EF. Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures. J Clin Med 2024; 13:3104. [PMID: 38892813 PMCID: PMC11172990 DOI: 10.3390/jcm13113104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/15/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.
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Affiliation(s)
| | | | | | - Enrique F. Elli
- Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
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Castillo-Larios R, Cornejo J, Gunturu NS, Cheng YL, Elli EF. Experience of Robotic Complex Revisional Bariatric Surgery in a High-Volume Center. Obes Surg 2023; 33:4034-4041. [PMID: 37919532 DOI: 10.1007/s11695-023-06916-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE A revisional bariatric surgery (RBS) is necessary in about 28% of the patients. The role of robotic surgery in RBS is still a subject of debate. We aim to report the outcomes of robotic-assisted RBS at our institution. MATERIALS AND METHODS We identified patients who underwent robotic-assisted RBSs between January 1, 2016, and May 31, 2022. We analyzed patient demographics and indications for surgery. Measured outcomes included peri- and postoperative morbidity, comorbidity management, and weight loss outcomes. RESULTS A total of 106 patients were included. Primary procedures were adjustable gastric band 44 (41.5%), sleeve gastrectomy 42 (39.6%), Roux-en-Y gastric bypass (RYGB) 18 (17%), duodenal switch (DS) 1 (0.9%), and vertical banded gastroplasty 1 (0.9%). RBSs performed included 85 (78.7%) RYGB, 16 (14.8%) redo-gastrojejunostomy, and 5 (4.6%) DS. The median time to revision was 8 (range 1-36) years, and the main indication was insufficient weight loss (49%). Median length of hospital stay was 2 (range 1-16) days, and 9 (8.5%) patients were readmitted during the first 30 days. Only 4 (3.7%) patients had early Clavien-Dindo grade III or higher adverse events. No anastomotic leaks were documented. Median excess weight loss was 35.1%, 42.23%, and 45.82% at the 6-, 12-, and 24-month follow-up. Of 57 patients with hypertension, 29 (50.9%) reduced their medication dosage, and 20/27 (74.1%) reduced their diabetes mellitus medication dosage. Finally, of the 75 patients with symptoms, 64 (85.3%) reported an improvement after the RBS. CONCLUSION Robotic-assisted RBS is feasible, significantly improves patients' comorbidities and symptoms, and leads to considerable weight loss.
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Affiliation(s)
- Rocio Castillo-Larios
- Department of General Surgery, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Jorge Cornejo
- Department of General Surgery, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Naga Swati Gunturu
- Department of General Surgery, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Yilon Lima Cheng
- Department of General Surgery, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Enrique F Elli
- Department of General Surgery, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Coelho-Prabhu N, Forbes N, Thosani NC, Storm AC, Pawa S, Kohli DR, Fujii-Lau LL, Elhanafi S, Calderwood AH, Buxbaum JL, Kwon RS, Amateau SK, Al-Haddad MA, Qumseya BJ. Adverse events associated with EGD and EGD-related techniques. Gastrointest Endosc 2022; 96:389-401.e1. [PMID: 35843754 DOI: 10.1016/j.gie.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Divyanshoo R Kohli
- Division of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Larissa L Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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9
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Spota A, Cereatti F, Granieri S, Antonelli G, Dumont JL, Dagher I, Chiche R, Catheline JM, Pourcher G, Rebibo L, Calabrese D, Msika S, Tranchart H, Lainas P, Danan D, Tuszynski T, Pacini F, Arienzo R, Trelles N, Soprani A, Lazzati A, Torcivia A, Genser L, Derhy S, Fazi M, Bouillot JL, Marmuse JP, Chevallier JM, Donatelli G. Endoscopic Management of Bariatric Surgery Complications According to a Standardized Algorithm. Obes Surg 2021; 31:4327-4337. [PMID: 34297256 DOI: 10.1007/s11695-021-05577-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/23/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Endoscopy is effective in management of bariatric surgery (BS) adverse events (AEs) but a comprehensive evaluation of long-term results is lacking. Our aim is to assess the effectiveness of a standardized algorithm for the treatment of BS-AE. PATIENTS AND METHODS We retrospectively analyzed 1020 consecutive patients treated in our center from 2012 to 2020, collecting data on demographics, type of BS, complications, and endoscopic treatment. Clinical success (CS) was evaluated considering referral delay, healing time, surgery, and complications type. Logistic regression was performed to identify variables of CS. RESULTS In the study period, we treated 339 fistulae (33.2%), 324 leaks (31.8%), 198 post-sleeve gastrectomy twist/stenosis (19.4%), 95 post-RYGB stenosis (9.3 %), 37 collections (3.6%), 15 LAGB migrations (1.5%), 7 weight regains (0.7%), and 2 hemorrhages (0.2%). Main endoscopic treatments were as follows: pigtail-stent positioning under endoscopic view for both leaks (CS 86.1%) and fistulas (CS 77.2%), or under EUS-guidance for collections (CS 88.2%); dilations and/or stent positioning for sleeve twist/stenosis (CS 80.6%) and bypass stenosis (CS 81.5%). After a median (IQR) follow-up of 18.5 months (4.29-38.68), complications rate was 1.9%. We found a 1% increased risk of redo-surgery every 10 days of delay to the first endoscopic treatment. Endoscopically treated patients had a more frequent regular diet compared to re-operated patients. CONCLUSIONS Endoscopic treatment of BS-AEs following a standardized algorithm is safe and effective. Early endoscopic treatment is associated with an increased CS rate.
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Affiliation(s)
- Andrea Spota
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 8 Place de l'Abbé G. Hénocque, 75013, Paris, France.,Università degli studi di Milano, Scuola di Specializzazione in Chirurgia Generale, Milan, Italy
| | - Fabrizio Cereatti
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 8 Place de l'Abbé G. Hénocque, 75013, Paris, France.,Ospedale dei Castelli, ASL Roma 6, Via Nettunense km 115, 00040 Ariccia, Roma, Italy
| | - Stefano Granieri
- General Surgery Unit, ASST-Vimercate, Via Santi Cosma e Damiano 10, 20871, Vimercate, Italy
| | - Giulio Antonelli
- Ospedale dei Castelli, ASL Roma 6, Via Nettunense km 115, 00040 Ariccia, Roma, Italy
| | - Jean-Loup Dumont
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 8 Place de l'Abbé G. Hénocque, 75013, Paris, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Renaud Chiche
- Service de Chirurgie digestive et de l'Obésité, Clinique Geoffry Saint Hilaire, Paris, France
| | - Jean-Marc Catheline
- Department of Digestive Surgery, Centre Hospitalier de Saint - Denis, Saint - Denis, France
| | - Guillaume Pourcher
- Department of Digestive Diseases, Obesity Center, Institut Mutualiste Montsouris, Paris Descartes University, Paris, France
| | - Lionel Rebibo
- Service de chirurgie digestive œsogastrique et bariatrique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Daniela Calabrese
- Service de chirurgie digestive œsogastrique et bariatrique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Simon Msika
- Service de chirurgie digestive œsogastrique et bariatrique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - David Danan
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 8 Place de l'Abbé G. Hénocque, 75013, Paris, France
| | - Thierry Tuszynski
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 8 Place de l'Abbé G. Hénocque, 75013, Paris, France
| | - Filippo Pacini
- Centre Obésité Paris Peupliers, Hôpital Privé des Peupliers, Ramsay Santé, Paris, France
| | - Roberto Arienzo
- Centre Obésité Paris Peupliers, Hôpital Privé des Peupliers, Ramsay Santé, Paris, France
| | - Nelson Trelles
- Service de Chirurgie Générale et Digestive, Centre Hospitalier Rene Dubos, Pontoise, France
| | - Antoine Soprani
- Service de Chirurgie digestive et de l'Obésité, Clinique Geoffry Saint Hilaire, Paris, France
| | - Andrea Lazzati
- Department of Digestive Surgery, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Adriana Torcivia
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Hepato-Biliary and Pancreatic Surgery, Pitié-Salpêtrière University Hospital, Sorbonne Université, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Laurent Genser
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Hepato-Biliary and Pancreatic Surgery, Pitié-Salpêtrière University Hospital, Sorbonne Université, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Serge Derhy
- Unité de Radiologie Interventionnelle, Hôpital Privé des Peupliers, Paris, France
| | - Maurizio Fazi
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 8 Place de l'Abbé G. Hénocque, 75013, Paris, France
| | - Jean-Luc Bouillot
- Service de Chirurgie Digestive et Obésité, Hôpital Paris Saint-Joseph, Paris, France
| | | | - Jean-Marc Chevallier
- Centre Obésité Paris Peupliers, Hôpital Privé des Peupliers, Ramsay Santé, Paris, France
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 8 Place de l'Abbé G. Hénocque, 75013, Paris, France.
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10
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Castaneda D, Azar FF, Hussain I, Hasan B, Charles R, Pimentel R, Castro FJ. Clinical and Endoscopic Predictors of Hydrostatic Balloon Dilation Failure for Post-Bariatric Anastomotic Stricture Treatment. Obes Surg 2021; 31:2935-2941. [PMID: 33761069 DOI: 10.1007/s11695-021-05353-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/06/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) patients can develop anastomotic strictures. The initial management relies on endoscopic hydrostatic balloon dilation, but in a subset of patients, it may be unsuccessful despite several dilations, requiring a different treatment modality. We evaluated the factors associated with balloon dilation failure and need for revision surgery. METHODS Retrospective analysis from patients presenting with a post-RYGB anastomotic stricture who underwent balloon dilation from 2005 to 2018 at Cleveland Clinic Florida and Cleveland Clinic Main Campus. Demographic, clinical, surgical, endoscopic, and post-procedural variables were collected. Univariate and multivariate analysis with odds ratio (OR) and 95% confidence interval (95% CI) calculation for factors associated to dilation failure was performed. RESULTS Eighty-nine patients were included in the analysis. Population was predominantly white (85.4%) and female (87.6%), with mean age 46.4 years and followed for a mean of 97.4 months. All patients presented dysphagia, with mean stricture diameter of 7.7 mm and associated marginal ulcer in 69%. Successful dilation was achieved in 65 patients, while 24 patients had dilation failure and underwent revisional surgery. Multivariate analysis showed a higher risk of dilation failure if time from RYGB to first dilation was >3 months (OR 4.95, 1.29-19.04; p = 0.02), and if nausea/vomiting were present before first dilation (OR 4.37, 1.11-17.16; p = 0.03). One patient had a perforation after dilation and was treated surgically. CONCLUSIONS Post-RYGB anastomotic strictures can be successfully treated with hydrostatic balloon dilation. However, patients with dilations performed > 3 months after initial RYGB and nausea/vomiting have an increased risk of dilation failure and need for further interventions.
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Affiliation(s)
- Daniel Castaneda
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA.
| | - Francisco Franco Azar
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Ishtiaq Hussain
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Badar Hasan
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Roger Charles
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Ronnie Pimentel
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Fernando J Castro
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
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11
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Chen W, Chen I, Chen T, Hsu M, Tsai Y, Tai C. Endoscopic balloon dilation for gastrojejunal anastomotic stricture after
Roux‐en‐Y
gastric bypass: A case series. ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Wen‐Hsu Chen
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - I‐Sung Chen
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - Tzu‐Haw Chen
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - Ming‐Hung Hsu
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - Ying‐Nan Tsai
- Department of Internal Medicine E‐Da Cancer Hospital Kaohsiung Taiwan
| | - Chi‐Ming Tai
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
- School of Medicine College of Medicine, I‐Shou University Kaohsiung Taiwan
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12
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Role of Robotic Surgery in Complex Revisional Bariatric Procedures. Obes Surg 2021; 31:2583-2589. [PMID: 33646519 DOI: 10.1007/s11695-021-05272-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Revisional bariatric surgery (RBS) is becoming more common, with an estimated increase of more than 300% from 2017 to 2018. For these complex procedures, the role of robotics is still debated. The purpose of our study is to report the safety and effectiveness of robotic-assisted RBSs. MATERIALS AND METHODS A retrospective review of electronic medical records was conducted for robotic-assisted RBSs performed at the Mayo Clinic in Florida, between January 1, 2016, and January 1, 2020. Peri- and postoperative data were analyzed, reviewing patient characteristics, indications for surgery, and outcomes. RESULTS From 160 RBSs performed during the study period, 67 were robotic-assisted and met inclusion criteria. Primary procedures included sleeve gastrectomy (26 [38.8%]), adjustable gastric band (24 [35.8%]), Roux-en-Y gastric bypass (14 [20.9%]), vertical-banded gastroplasty (2 [3.0%]), and duodenal switch (1 [1.5%]). RBSs performed were Roux-en-Y gastric bypass (49 [73.1%]), redo gastrojejunostomy (14 [20.9%]), and duodenal switch (4 [6.0%]). Rate of conversion to open procedure and rate of readmission 1 month after surgery were 6.0% and 7.5%, respectively. Rate of 30-day Clavien-Dindo grade III or higher adverse events was 4.5%. No anastomotic leaks were documented. Fifty-two patients presented with preoperative symptoms, and 69.2% reported improvement after RBS. Mean (SD) excess weight loss was 57.62% (23.80) 12 months after RBS. CONCLUSION Robotic-assisted RBSs are safe with low major adverse event rates. Symptom resolution and weight loss outcomes are acceptable.
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13
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Diaz-Vico T, Elli EF. Value of robotic-assisted technique in redo gastrojejunostomy for severe stenosis after gastric bypass. J Robot Surg 2019; 14:463-471. [PMID: 31463879 DOI: 10.1007/s11701-019-01009-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022]
Abstract
Development of gastrojejunal stricture following Roux-en-Y gastric bypass (RYGB) leads to an increase in morbidity and adverse effects, such as abdominal pain, vomiting, aspiration pneumonia, and malnutrition. Up to 38.5% of patients will require revisional surgery for late anastomotic strictures despite conservative treatment. However, no previous studies focused on revisional robotic bariatric surgery due to strictures after RYGB have been reported. To evaluate our outcomes and assess the advantages of the robotic platform with regard to laparoscopic and open revisional procedures. University Hospital. We performed a retrospective analysis of patients who underwent laparoscopic robotic-assisted redo gastrojejunostomy from 2016 to 2018. Demographics, surgical data, medical treatments, postoperative outcomes, and adverse effects were collected. Nine patients with symptomatic anastomotic strictures after primary RYGB underwent robotic revisional surgery. All patients received medical therapy as a first approach, and five patients (55.5%) underwent endoscopic balloon dilation. All procedures were successfully completed with robotic assistance, with a mean (standard deviation) operative time of 184.5 (49.1) min, and no intraoperative adverse effects were registered. Median (range) hospital stay was 2 (1-4) days. One patient presented with a postoperative intra-abdominal abscess and was treated with intravenous antibiotics and image-guided drainage. No anastomotic leak, hemorrhage, or mortality were reported. Robotic assistance seems to be safe and effective for redo gastrojejunostomy secondary to stricture. Even though the sample size is small, we believe that the application of robotic techniques may provide advantages and improve the outcomes in these complex revisional procedures.
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Affiliation(s)
- Tamara Diaz-Vico
- Division of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
| | - Enrique F Elli
- Division of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
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