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Khrucharoen U, Weitzner ZN, Chen Y, Dutson EP. Incidence and risk factors for early gastrojejunostomy anastomotic stricture requiring endoscopic intervention following laparoscopic Roux-en-Y gastric bypass: a MBSAQIP analysis. Surg Endosc 2022; 36:3833-3842. [PMID: 34471978 DOI: 10.1007/s00464-021-08700-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/23/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Gastrojejunostomy (GJ) stricture is one of the most commonly recognized complications following laparoscopic Roux-en-Y gastric bypass (LRYGB). The risks involving the formation of early GJ stomal stenosis are largely unknown. The aims of this study are to evaluate the rate and risk factors associated with GJ stricture in patients requiring esophagogastroduodenoscopy (EGD) within 30 days after LRYGB. METHODS This is a retrospective study of patients who underwent EGD for GJ stricture following LRYGB. Data were retrieved from MBSAQIP database from 2015 to 2018. Descriptive, bivariate, and logistic regression analyses were performed. Those who had reoperation, readmission, and intervention for other indications rather than GJ stricture were excluded from the risk factor analysis. RESULTS 760,076 patients underwent bariatric surgery. Of these, 184,660 (24.3%) underwent LRYGB and 875 had GJ stricture within 30 days postoperatively. The overall incidence of early GJ stricture after LRYGB was 4.7 per 1000 person-years. The incidence decreased from 6.2 to 3.4 per 1000 person-years during the 4-year period. 85% of patients with GJ stricture required therapeutic intervention. Median (IQR) day to the first endoscopic intervention was 25 (21-28) days. The overall 30-day readmission rate was 40%. 30-day reoperation rate due to GJ stricture was 5.6%. No 30-day mortality occurred. Factors independently associated with an increased risk for early GJ stricture include concurrent hiatal hernia repair (Adjusted Odds Ratio-AOR 1.8, 95% CI 1.5-2.2), revision case (AOR 1.4, 95% CI 1.1-1.6), African American (AOR 1.4, 95% CI 1.2-1.7), gastroesophageal reflux disease-GERD (AOR 1.4, 95% CI 1.2-1.5), drain placement (AOR 1.3, 95% CI1.1-1.4), and routine postoperative swallow study (AOR 1.3, 95% CI 1.1-1.50). CONCLUSION The incidence of early GJ stricture following LRYGB decreased at MBSAQIP-accredited centers over the review period. Patients having additional manipulation at or around GJ were at risk of developing early GJ stricture after LRYGB.
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Affiliation(s)
- Usah Khrucharoen
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA.,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA
| | - Zachary N Weitzner
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA.,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA
| | - Yijun Chen
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA
| | - Erik P Dutson
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA. .,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA. .,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA.
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Vilallonga R, Sanchez-Cordero S, Umpiérrez Mayor N, Molina A, Cirera de Tudela A, Ruiz-Úcar E, Carrasco MA. GERD after Bariatric Surgery. Can We Expect Endoscopic Findings? ACTA ACUST UNITED AC 2021; 57:medicina57050506. [PMID: 34067532 PMCID: PMC8156378 DOI: 10.3390/medicina57050506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 12/30/2022]
Abstract
Background and Objectives: Bariatric surgery remains the gold standard treatment for morbidly obese patients. Roux-en-y gastric bypass and laparoscopic sleeve gastrectomy are the most frequently performed surgeries worldwide. Obesity has also been related to gastroesophageal reflux disease (GERD). The management of a preoperative diagnosis of GERD, with/without hiatal hernia before bariatric surgery, is mandatory. Endoscopy can show abnormal findings that might influence the final type of surgery. The aim of this article is to discuss and review the evidence related to the endoscopic findings after bariatric surgery. Materials and Methods: A systematic review of the literature has been conducted, including all recent articles related to endoscopic findings after bariatric surgery. Our review of the literature has included 140 articles, of which, after final review, only eight were included. The polled articles included discussion of the endoscopy findings after roux-en-y gastric bypass and laparoscopic sleeve gastrectomy. Results: We found that the specific care of bariatric patients might include an endoscopic diagnosis when GERD symptoms are present. Conclusions: Recent evidence has shown that endoscopic follow-up after laparoscopic sleeve gastrectomy could be advisable, due to the pathological findings in endoscopic procedures in asymptomatic patients.
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Affiliation(s)
- Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, Department of General and Digestive Surgery, Center of Excellence for the EAC-BC, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Passeig de la Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- ELSAN, Clinique Saint Michel, Centre Chirurgical de l’Obésité, 83100 Toulon, France
| | - Sergi Sanchez-Cordero
- Department of General and Digestive Surgery, Igualada University Hospital, Av. Catalunya 11, Igualada, 08700 Barcelona, Spain
- Correspondence:
| | - Nicolas Umpiérrez Mayor
- Department of General and Digestive Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Passeig de la Vall d’Hebron 119-129, 08035 Barcelona, Spain; (N.U.M.); (A.C.d.T.); (M.A.C.)
| | - Alicia Molina
- UCON, Obesity and Nutrition Surgery Unit, Corachan Clinic, Tres Torres, 7, 08017 Barcelona, Spain;
| | - Arturo Cirera de Tudela
- Department of General and Digestive Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Passeig de la Vall d’Hebron 119-129, 08035 Barcelona, Spain; (N.U.M.); (A.C.d.T.); (M.A.C.)
| | - Elena Ruiz-Úcar
- Endocrine, Metabolic and Bariatric Unit, Department of General and Digestive Surgery, Fuenlabrada University Hospital, Rey Juan Carlos University, Camino del Molino, 2, 28942 Madrid, Spain;
| | - Manel Armengol Carrasco
- Department of General and Digestive Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Passeig de la Vall d’Hebron 119-129, 08035 Barcelona, Spain; (N.U.M.); (A.C.d.T.); (M.A.C.)
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3
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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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4
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A review of commonly performed bariatric surgeries: Imaging features and its complications. Clin Imaging 2020; 72:122-135. [PMID: 33232899 DOI: 10.1016/j.clinimag.2020.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/13/2020] [Accepted: 11/08/2020] [Indexed: 01/15/2023]
Abstract
Obesity is a disease that has achieved the level that can be considered an epidemic. According to the National Center for Health Statistics data, the prevalence of obesity has increased from 30.5% in 1999-2000 to 42.4% in 2017-2018. During the same period, severe obesity has increased from 4.7% to 9.2%. With the growing prevalence of obesity, related conditions such as coronary artery disease, diabetes, and strokes have also become more prevalent. In the past few years, the need for bariatric surgeries such as laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic adjustable gastric banding has increased considerably. With an increasing number of bariatric surgeries, multiple postoperative complications have become common. In this review, we have attempted to describe normal postsurgical anatomical findings after bariatric surgeries and pictorial review of a few common postoperative complications.
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5
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Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos). Gastrointest Endosc 2020; 92:492-507. [PMID: 32800313 DOI: 10.1016/j.gie.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
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.
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6
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Boerlage TCC, Wolvers PJD, Bruin SC, Huibregtse IL, Voermans RP, Fockens P, Hutten BA, Gerdes VEA. Upper endoscopy after Roux-en-Y gastric bypass: diagnostic yield and factors associated with relevant findings. Surg Obes Relat Dis 2020; 16:868-876. [PMID: 32299714 DOI: 10.1016/j.soard.2020.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/15/2020] [Accepted: 03/03/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND After laparoscopic Roux-en-Y gastric bypass many patients present with complaints for which an upper endoscopy is performed. However, often no abnormalities are found. OBJECTIVES To investigate the incidence of relevant findings at upper endoscopy and identify patient characteristics associated with a relevant finding. SETTING A high-volume bariatric center. METHODS A retrospective cohort study was performed. All patients presenting with complaints after laparoscopic Roux-en-Y gastric bypass who consequently underwent a diagnostic upper endoscopy were identified from a prospective endoscopic database. Primary outcomes were the number and type of relevant findings at upper endoscopy and its association with patient characteristics. Relevant findings were defined as abnormalities requiring treatment. RESULTS Ninety-eight (39.2%) of 250 patients had a relevant finding at upper endoscopy, mostly marginal ulcer and stomal stenosis. Male sex (odds ratio [OR] 3.47 [1.12-10.76]), alcohol consumption (OR 7.27 [1.58-33.36]), dysphagia or suspicion of bleeding as referral reason (OR 3.62 [1.54-8.52] and 39.93 [4.96-321.47], respectively, compared with abdominal pain), an abnormal upper gastrointestinal series (OR 6.81 [2.06-22.48]), and no abdominal ultrasound (OR 7.41 [1.48-37.08] compared with a normal ultrasound) were significantly associated with a relevant finding at upper endoscopy. CONCLUSIONS In this study sex, alcohol consumption, referral reason, and prior imaging studies were associated with a relevant finding at upper endoscopy after laparoscopic Roux-en-Y gastric bypass.
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Affiliation(s)
- Thomas C C Boerlage
- Department of Gastroenterology & Hepatology, St. Antonius Hospital, Utrecht, the Netherlands
| | - Paula J D Wolvers
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Sjoerd C Bruin
- Department of Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Inge L Huibregtse
- Department of Gastroenterology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Barbara A Hutten
- Department of Clinical Epidemiology and Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Victor E A Gerdes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Internal Medicine, Spaarne Gasthuis Hoofddorp, the Netherlands
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7
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Endoscopic Dilation of Bariatric RNY Anastomotic Strictures: a Systematic Review and Meta-analysis. Obes Surg 2019; 28:4053-4063. [PMID: 30244332 DOI: 10.1007/s11695-018-3491-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Gastrojejunostomy anastomotic strictures are a complication of Roux-en-Y gastric bypass surgery without an established treatment guideline. A systematic review and meta-analysis were performed to determine the safety and efficacy of endoscopic dilation in their management. PubMed, Web of Science, and Cochrane Central (1994-2017) were searched. Data was analyzed with random effects meta-analysis and mixed effects meta-regression. Twenty-one observational studies (896 patients) were included. The stricture rate for laparoscopic patients was 6% (95% CI, 5-9%). Only 38% (95% CI, 30-47%) required greater than one dilation. Symptom improvement occurred in 97% (95% CI, 94-98%). The complication rate was 4% (95% CI, 3-6%). Endoscopic dilation of GJA strictures is safe, effective, and sustaining. This study can guide endoscopists in the treatment of a common bariatric surgical complication.
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8
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9
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Schulman AR, Thompson CC. Complications of Bariatric Surgery: What You Can Expect to See in Your GI Practice. Am J Gastroenterol 2017; 112:1640-1655. [PMID: 28809386 DOI: 10.1038/ajg.2017.241] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023]
Abstract
Obesity is one of the most significant health problems worldwide. Bariatric surgery has become one of the fastest growing operative procedures and has gained acceptance as the leading option for weight-loss. Despite improvement in the performance of bariatric surgical procedures, complications are not uncommon. There are a number of unique complications that arise in this patient population and require specific knowledge for proper management. Furthermore, conditions unrelated to the altered anatomy typically require a different management strategy. As such, a basic understanding of surgical anatomy, potential complications, and endoscopic tools and techniques for optimal management is essential for the practicing gastroenterologist. Gastroenterologists should be familiar with these procedures and complication management strategies. This review will cover these topics and focus on major complications that gastroenterologists will be most likely to see in their practice.
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Affiliation(s)
- Allison R Schulman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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10
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Joo MK. Endoscopic Approach for Major Complications of Bariatric Surgery. Clin Endosc 2016; 50:31-41. [PMID: 28008162 PMCID: PMC5299989 DOI: 10.5946/ce.2016.140] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022] Open
Abstract
As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.
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Affiliation(s)
- Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul, Korea
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11
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Boules M, Chang J, Haskins IN, Sharma G, Froylich D, El-Hayek K, Rodriguez J, Kroh M. Endoscopic management of post-bariatric surgery complications. World J Gastrointest Endosc 2016; 8:591-599. [PMID: 27668069 PMCID: PMC5027029 DOI: 10.4253/wjge.v8.i17.591] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/02/2016] [Accepted: 07/22/2016] [Indexed: 02/05/2023] Open
Abstract
Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early (< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late (> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.
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12
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Malli CP, Sioulas AD, Emmanouil T, Dimitriadis GD, Triantafyllou K. Endoscopy after bariatric surgery. Ann Gastroenterol 2016; 29:249-57. [PMID: 27366025 PMCID: PMC4923810 DOI: 10.20524/aog.2016.0034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/08/2016] [Indexed: 12/16/2022] Open
Abstract
Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.
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Affiliation(s)
- Chrysoula P. Malli
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Athanasios D. Sioulas
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Theodoros Emmanouil
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - George D. Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
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Parikh M, Gagner M. Laparoscopic Revision of Gastrogastric Stricture With a Transoral Circular Stapler. Surg Innov 2016; 14:225-30. [DOI: 10.1177/1553350607308306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Most anastomotic strictures can be effectively managed by endoscopic dilations. Patients with severe strictures refractory to balloon dilations may require surgical revision. Revision of a strictured anastomosis (open or laparoscopic) is often technically demanding because of the severity of adhesion formation and difficulty in correctly identifying the anatomy. We discuss a laparoscopic method of safely revising an anastomotic stricture with a circular stapler.
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Affiliation(s)
- Manish Parikh
- Laparoscopic and Bariatric Surgery, Joan and Sanford I. Weill College of Medicine of Cornell University, New York-Presbyterian Hospital, New York, New York
| | - Michel Gagner
- Laparoscopic and Bariatric Surgery, Joan and Sanford I. Weill College of Medicine of Cornell University, New York-Presbyterian Hospital, New York, New York, ,
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14
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Complications of bariatric surgery – What the general surgeon needs to know. Surgeon 2016; 14:91-8. [DOI: 10.1016/j.surge.2015.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 07/13/2015] [Accepted: 08/12/2015] [Indexed: 12/18/2022]
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15
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16
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Endoscopic balloon dilatation as an effective treatment for lower and upper benign gastrointestinal system anastomotic stenosis. Surg Laparosc Endosc Percutan Tech 2016; 25:138-42. [PMID: 25122484 DOI: 10.1097/sle.0000000000000090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Endoscopic balloon dilatation (EBD) is currently accepted as an effective, safe, and first-line treatment of postoperative benign gastrointestinal anastomosis stenosis (BGAS); however, a limited number of publications on the subject exist in the literature. The aim of the study was to retrospectively evaluate the efficiency of endoscopic dilatation in patients with postoperative intestinal anastomotic stenoses at a single surgical center. METHODS Patients with postoperative BGAS treated by EBD at our institution from February 2008 to 2012 were included. The dilatations were all performed using through-the-scope balloons. The balloon was introduced into the stricture using a guidewire under radiologic guidance. Each dilatation session consisted of 2 to 3 two-minute multistep inflations of the balloon until adequate dilatation was achieved. RESULTS Of the 48 patients included in the study, 44 patients (91.7%) fully recovered and 4 (8.3%) did not respond to treatment. The mean follow-up period was 24 months (range, 3 to 57 mo). Four patients who did not respond to the procedure were treated surgically. Two patients (4.1%) with intestinal perforation during EBD were treated conservatively with a stent. CONCLUSIONS EBD has a low rate of complications and a high success rate, is well tolerated, and avoids further surgical procedures for BGAS. Therefore, EBD should be the first choice of treatment for postoperative anastomotic stenoses.
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17
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de Moura EGH, Orso IRB, Aurélio EF, de Moura ETH, de Moura DTH, Santo MA. Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2015; 12:582-586. [PMID: 27174245 DOI: 10.1016/j.soard.2015.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 11/02/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Roux-en-Y gastric bypass is a commonly used technique of bariatric surgery. One of the most important complications is gastrojejunal anastomotic stricture. Endoscopic balloon dilation appears to be well tolerated and effective, but well-designed randomized, controlled trials have not yet been conducted. OBJECTIVE Identify factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. SETTING Gastrointestinal endoscopy service, university hospital, Brazil. METHODS The records of 64 patients with anastomotic stricture submitted to endoscopic dilation with hydrostatic balloon dilation were reviewed. Information was collected on gastric pouch length, anastomosis diameter before dilation, number of dilation sessions, balloon diameter at each session, anastomosis diameter after the last dilation session, presence of postsurgical complications, endoscopic complications, and outcome of dilation. Comparisons were made among postsurgical and endoscopic complications; number of dilations, balloon diameter; anastomosis diameter before dilation; and dilation outcome. RESULTS Success of dilation treatment was 95%. Perforation was positively and significantly associated with the number of dilation sessions (P = .03). Highly significant associations were found between ischemic segment and perforation (P<.001) and between ischemic segment and bleeding (P = .047). Ischemic segment (P = .02) and fistula (P = .032) were also associated with dilation failure. CONCLUSION Ischemic segment and fistula were found to be important risk factors for balloon dilation failure. The greater the number of dilation sessions, the greater the number of endoscopic complications.
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Affiliation(s)
- Eduardo G H de Moura
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Gastrointestinal Endoscopy Service, Hospital São Luiz Morumbi, São Paulo, Brazil
| | - Ivan R B Orso
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Gastroclínica Cascavel - Assis Gurgacz Medical School, Paraná, Brazil.
| | - Eduardo F Aurélio
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Eduardo T H de Moura
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Diogo T H de Moura
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marco A Santo
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW Bariatric surgery is recognized as the most effective treatment against obesity as it results in significant weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. This review illustrates the latest developments in the endoscopic management of bariatric surgical complications. RECENT FINDINGS For successful management of complications, precipitating and perpetuating factors must be addressed in addition to directing therapy at the target pathology. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Chronic proximal staple-line leaks/fistulas frequently do not respond to primary closure with diversion therapy, and a new technique of stricturotomy has been reported to improve outcomes. Innovations in the field of transoral endoscopic instruments have led to the development of a single-session entirely internal endoscopic retrograde cholangiopancreatography by creating a gastrogastric anastomosis. SUMMARY Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention. Computed tomography-guided drainage may be necessary in patients with drainable fluid collections. VIDEO ABSTRACT http://links.lww.com/COG/A11.
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Incidence of gastrojejunostomy stricture in laparoscopic Roux-en-Y gastric bypass using an autologous fibrin sealant. Obes Surg 2015; 24:1052-6. [PMID: 24599874 DOI: 10.1007/s11695-014-1204-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anastomotic leak at the gastrojejunostomy is a life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Fibrin sealants have been used as topical adjuncts to reduce leaks at the gastrojejunostomy. Our clinical observations suggest that an unintended consequence may be the promotion of anastomotic stricture. We hypothesized that the use of fibrin sealant at the gastrojejunostomy in patients undergoing LRYGB decreases the incidence of anastomotic leak but increases the incidence of clinically significant stricture. METHODS Following institutional review board approval, medical records of patients undergoing LRYGB by two surgeons at a single institution over a 5-year period were retrospectively reviewed. Preoperative demographics and postoperative complication rates including incidence of gastrojejunostomy leak and endoscopically diagnosed stricture requiring dilation within 1 year of surgery were recorded. RESULTS Four hundred twenty-five patients had fibrin sealant routinely applied to their gastrojejunostomy site and 104 did not. Four leaks occurred in the sealant group and two leaks occurred in the control group (p = 0.2). Of patients who received sealant, 1.6 % needed postoperative blood transfusion compared to 4.8%of those who did not receive sealant (p=0.05) [corrected]. There was a significantly increased rate of strictures requiring dilation in the sealant group (11.3% compared to 4.8% stricture rate in patients who did not receive sealant, p = 0.04). CONCLUSIONS In our experience, the use of fibrin sealant at linear stapled gastrojejunostomy site during LRYGB increases the incidence of clinically significant postoperative stricture and does not reduce the incidence of anastomotic leak.
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Adverse events associated with endoscopic dilation for gastric stenosis after endoscopic submucosal dissection for early gastric cancer. Surg Endosc 2015; 29:3776-82. [PMID: 25783836 DOI: 10.1007/s00464-015-4153-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/06/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Gastric stenosis is a major problem after endoscopic submucosal dissection (ESD) for large early gastric cancer, but little is known about the incidence of adverse events associated with endoscopic dilation (ED) for stenosis caused by gastric ESD. The aims of this study were to determine the incidence and risk of bleeding and perforation associated with ED for gastric stenosis after ESD. METHODS This was a single-center, retrospective cohort study conducted at a specialized center for treating cancer. A total of 342 procedures of wire-guided balloon ED were performed for stenosis after gastric ESD in 64 patients. The incidence of adverse events and related clinical characteristics was analyzed. RESULTS The incidence of bleeding was 3.1% (2/64) per patient and 0.6% (2/342) per procedure. One bleeding case with incomplete cessation of antithrombotics before ED required blood transfusion. The incidence of perforation was 7.8% (5/64) per patient and 1.5% (5/342) per procedure. All perforations occurred in the lower part of the stomach. Two of the five perforation cases were inappropriate for nonoperative therapy, and thus, emergency surgery was performed. Among the other three perforation cases, one case required surgery for refractory stenosis and ED was continued in one case after nonoperative therapy. CONCLUSIONS The incidence of bleeding caused by ED for gastric stenosis after ESD was small. Although not significant, ED in the lower stomach presents a substantial risk of perforation.
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Ribeiro-Parenti L, Arapis K, Chosidow D, Dumont JL, Demetriou M, Marmuse JP. Gastrojejunostomy stricture rate: comparison between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2015; 11:1076-84. [PMID: 25892346 DOI: 10.1016/j.soard.2015.01.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/15/2015] [Accepted: 01/26/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass procedure is an effective treatment for morbid obesity. One of the most frequent complications after this operation is the appearance of a gastrojejunal anastomotic stricture. Mechanisms underlying the development of such complication are unclear. OBJECTIVE The aim of the present retrospective study was to compare the rates of gastrojejunostomy stricture between the antecolic and retrocolic technique in a large cohort of patients undergoing Roux-en-Y gastric bypass for morbid obesity, with the same gastrojejunal anastomotic technique. SETTING University Hospital, France. METHODS From November 2000 to March 2012, 1500 patients underwent laparoscopic Roux-en-Y gastric bypass. The antecolic and the retrocolic technique were used in respectively 572 and 928 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy and absorbable sutures. RESULTS There was no significant difference with respect to gender, age, body mass index, and obesity related co-morbidities between both groups. Patients were followed for 24-146 months (mean 67.5 mo). Fifty-one patients developed a gastrojejunal stricture (3.4%), 37 in the antecolic group (6.5%) and 14 in the retrocolic group (1.5%). The difference was significant (P< .0001). The mean time to onset of gastrojejunal stricture symptoms after surgery was 1 month, ranging from 1 to 3 months. All patients were successfully treated using Savary-Gilliard dilatators. All patients with a gastrojejunal stricture were followed up for a minimum of 36 months. No recurrence was observed and no revisional surgery was needed. Weight loss was similar in patients who developed an anastomotic stricture compared with those without stricture. In the antecolic group internal hernia occurred in 12 of the 110 with no closure of mesenteric defects and in 8 of the 462 (1.7%) with defects closed. In the retrocolic group, 11 patients (1.2%) developed an internal hernia. CONCLUSIONS A significant lower gastrojejunal stricture rate was observed in the retrocolic group, with no increased risk of internal hernia, when mesenteric defects were closed. The antecolic technique seems to be a risk factor for gastrojejunal stricture development after laparoscopic gastric bypass.
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Affiliation(s)
- Lara Ribeiro-Parenti
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France.
| | - Konstantinos Arapis
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France
| | - Denis Chosidow
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France
| | - Jean-Loup Dumont
- Service d'Endoscopie Digestive. Hôpital Privé des Peupliers, Paris, France
| | - Monique Demetriou
- Service de d'Anesthésie Réanimation, Hôpital Bichat Claude Bernard, Paris, France
| | - Jean-Pierre Marmuse
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France
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Mathus-Vliegen EMH. The cooperation between endoscopists and surgeons in treating complications of bariatric surgery. Best Pract Res Clin Gastroenterol 2014; 28:703-25. [PMID: 25194185 DOI: 10.1016/j.bpg.2014.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/18/2014] [Accepted: 07/05/2014] [Indexed: 02/09/2023]
Abstract
The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.
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Affiliation(s)
- E M H Mathus-Vliegen
- Academic Medical Centre, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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De Palma GD, Forestieri P. Role of endoscopy in the bariatric surgery of patients. World J Gastroenterol 2014; 20:7777-7784. [PMID: 24976715 PMCID: PMC4069306 DOI: 10.3748/wjg.v20.i24.7777] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/31/2013] [Accepted: 03/10/2014] [Indexed: 02/06/2023] Open
Abstract
Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett’s esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett’s esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.
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Levine MS, Carucci LR. Imaging of bariatric surgery: normal anatomy and postoperative complications. Radiology 2014; 270:327-41. [PMID: 24471382 DOI: 10.1148/radiol.13122520] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Obesity is a disease that has reached epidemic proportions in the United States and around the world. During the past 2 decades, bariatric surgery has become an increasingly popular form of treatment for morbid obesity. The most common bariatric procedures performed include laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy. Fluoroscopic upper gastrointestinal examinations and abdominal computed tomography (CT) are the major imaging tests used to evaluate patients after these various forms of bariatric surgery. The purpose of this article is to present the surgical anatomy and normal imaging findings and postoperative complications for these bariatric procedures at fluoroscopic examinations and CT. Complications after Roux-en-Y gastric bypass include anastomotic leaks and strictures, marginal ulcers, jejunal ischemia, small bowel obstruction, internal hernias, intussusception, and recurrent weight gain. Complications after laparoscopic adjustable gastric banding include stomal stenosis, malpositioned bands, pouch dilation, band slippage, perforation, gastric volvulus, intraluminal band erosion, and port- and band-related problems. Finally, complications after sleeve gastrectomy include postoperative leaks and strictures, gastric dilation, and gastroesophageal reflux. The imaging features of these various complications of bariatric surgery are discussed and illustrated.
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Affiliation(s)
- Marc S Levine
- From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (M.S.L.); and Department of Radiology, VCU Medical Center, Richmond, VA (L.R.C.)
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Medbery RL, Coefield R, Patel AD, Pettitt BJ, Singh A, Srinivasan JK, Woods K, Davis SS. Endoscopic Management of Gastrojejunostomy Strictures: One Institution's Approach. Bariatr Surg Pract Patient Care 2014. [DOI: 10.1089/bari.2014.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Rachel L. Medbery
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Coefield
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ankit D. Patel
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Barbara J. Pettitt
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Arvinpal Singh
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Kevin Woods
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - S. Scott Davis
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Lee HJ, Park W, Lee H, Lee KH, Park JC, Shin SK, Lee SK, Lee YC, Noh SH. Endoscopy-guided balloon dilation of benign anastomotic strictures after radical gastrectomy for gastric cancer. Gut Liver 2014; 8:394-9. [PMID: 25071904 PMCID: PMC4113056 DOI: 10.5009/gnl.2014.8.4.394] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/29/2013] [Accepted: 07/16/2013] [Indexed: 12/27/2022] Open
Abstract
Background/Aims The aim of this study was to evaluate the outcome of endoscopic dilation for benign anastomotic stricture after radical gastrectomy in gastric cancer patients. Methods Gastric cancer patients who underwent endoscopic balloon dilation for benign anastomosis stricture after radical gastrectomy during a 6-year period were reviewed retrospectively. Results Twenty-one patients developed benign strictures at the site of anastomosis. The majority of strictures occurred within 1 year after surgery (95.2%). The median duration to stenosis after surgery was 1.70 months (range, 0.17 to 23.97 months). The success rate of the first endoscopic dilation was 61.9%. Between the restenosis group (n=8) and the no restenosis group (n=13), there were no significant differences in the body mass index (22.82 kg/m2 vs 22.46 kg/m2), interval to symptom onset (73.9 days vs 109.3 days), interval to treatment (84.6 days vs 115.6 days), maximal balloon diameter (14.12 mm vs 15.62 mm), number of balloon dilation sessions (1.75 vs 1.31), location of gastric cancer or type of surgery. One patient required surgery because of stricture refractory to repeated dilation. Conclusions Endoscopic dilation is a highly effective treatment for benign anastomotic strictures after radical gastrectomy for gastric cancer and should be considered a primary intervention prior to proceeding with surgical revision.
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Affiliation(s)
- Hyun Jik Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Wan Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Ho Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Campos JM, Mello FSTD, Ferraz AAB, Brito JND, Nassif PAN, Galvão-Neto MDP. Endoscopic dilation of gastrojejunal anastomosis after gastric bypass. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 25:283-9. [PMID: 23411930 DOI: 10.1590/s0102-67202012000400014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 04/17/2012] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Roux-en-Y gastric bypass may result in stenosis of the gastrojejunal anastomosis. There is currently no well-defined management protocol for this complication. AIM Through systematic review, to analyze the results of endoscopic dilation in patients with stenosis, including complication and success rates. METHODS The PubMed database was searched for relevant studies published each year from 1988 to 2010, and 23 studies were identified for analysis. Only papers describing the treatment of anastomotic stricture after Roux-en-Y gastric bypass were included, and case reports featuring less than three patients were excluded. RESULTS The mean age of the trial populations was 42.3 years and mean preoperative body mass index was 48.8 kg/m². A total of 1,298 procedures were undertaken in 760 patients (81% female), performing 1.7 dilations per patient. Through-the-scope balloons were used in 16 studies (69.5%) and Savary-Gilliard bougies in four. Only 2% of patients required surgical revision after dilation; the reported complication rate was 2.5% (n=19). Annual success rate was greater than 98% each year from 1992 to 2010, except for a 73% success rate in 2004. Seven studies reported complications, being perforation the most common, reported in 14 patients (1.82%) and requiring immediate operation in two patients. Other complications were also reported: one esophageal hematoma, one Mallory-Weiss tear, one case of severe nausea and vomiting, and two cases of severe abdominal pain. CONCLUSION Endoscopic treatment of stenosis is safe and effective; however, further high-quality randomized controlled trials should be conducted to confirm these findings.
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Kim KH, Kim MC, Jung GJ. Risk factors associated with delayed gastric emptying after subtotal gastrectomy with Billroth-I anastomosis using circular stapler for early gastric cancer patients. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:274-80. [PMID: 23166886 PMCID: PMC3491229 DOI: 10.4174/jkss.2012.83.5.274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 07/30/2012] [Accepted: 08/05/2012] [Indexed: 11/30/2022]
Abstract
Purpose Gastric surgery may potentiate delayed gastric emptying. Billroth I gastroduodenostomy using a circular stapler is the most preferable reconstruction method. The purpose of this study is to analyze the risk factors associated with delayed gastric emptying after radical subtotal gastrectomy with Billroth I anastomosis using a stapler for early gastric cancer. Methods Three hundred and seventy-eight patients who underwent circular stapled Billroth I gastroduodenostomy after subtotal gastrectomy due to early gastric cancer were analyzed retrospectively. One hundred and eighty-two patients had Billroth I anastomosis using a 25 mm diameter circular stapler, and 196 patients had anastomosis with a 28 or 29 mm diameter circular stapler. Clinicopathological features and postoperative outcomes were evaluated and compared between the two groups. Delayed gastric emptying was diagnosed by symptoms and simple abdomen X-ray with or without upper gastrointestinal series or endoscopy. Results Postoperative delayed gastric emptying was found in 12 (3.2%) of the 378 patients. Among all the variables, distal margin and circular stapler diameter were significantly different between the cases with delayed gastric emptying and no delayed gastric emptying. There were statistically significant differences in sex, body mass index, comorbidity, complication, and operation type according to circular stapler diameter. In both univariate and multivariate logistic regression analyses, only the stapler diameter was found to be a significant factor affecting delayed gastric emptying (P = 0.040). Conclusion In this study, the circular stapler diameter was one of the most significant predictable factors of delayed gastric emptying for Billroth I gastroduodenostomy. The use of a 28 or 29 mm diameter circular stapler rather than a 25 mm diameter stapler in stapled gastroduodenostomy for early gastric cancer can reduce postoperative delayed gastric emptying associated with anastomosic stenosis or edema with relative safety.
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Affiliation(s)
- Ki Han Kim
- Department of Surgery, Dong-A University College of Medicine, Busan, Korea
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30
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Espinel J, Pinedo E. Stenosis in gastric bypass: Endoscopic management. World J Gastrointest Endosc 2012; 4:290-5. [PMID: 22816008 PMCID: PMC3399006 DOI: 10.4253/wjge.v4.i7.290] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 05/02/2012] [Accepted: 07/01/2012] [Indexed: 02/05/2023] Open
Abstract
Gastric bypass is a treatment option for morbid obesity. Stenosis of the gastrojejunal anastomosis is a recognized complication. The pathophysiological mechanisms involved in the formation of stenosis are not well known. Gastrojejunal strictures can be classified based on time of onset, mechanism of formation, and endoscopic aspect. Diagnosis is usually obtained by endoscopy. The two main treatment alternatives for stomal stricture are: endoscopic dilatation (balloon or bouginage) and surgical revision (open or laparoscopic). Both techniques of dilation [through-the-scope (TTS) balloon dilators, Bougienage dilators] are considered safe, effective, and do not require hospitalization. The optimal technique for dilation of stomal strictures remains to be determined, but many authors prefer the use of TTS balloon catheters. Most patients can be successfully treated with 1 or 2 sessions. The need for reconstructive surgery of a stomal stricture is extremely rare.
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Affiliation(s)
- Jesús Espinel
- Jesús Espinel, Endoscopy Unit, Gastroenterology Department, Hospital de León, 24071 León, Spain
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Yimcharoen P, Heneghan H, Chand B, Talarico JA, Tariq N, Kroh M, Brethauer SA. Successful management of gastrojejunal strictures after gastric bypass: is timing important? Surg Obes Relat Dis 2012; 8:151-7. [DOI: 10.1016/j.soard.2011.01.043] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 01/12/2011] [Accepted: 01/28/2011] [Indexed: 01/26/2023]
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Swanson CM, Roust LR, Miller K, Madura JA. What every hospitalist should know about the post-bariatric surgery patient. J Hosp Med 2012; 7:156-63. [PMID: 22086862 DOI: 10.1002/jhm.939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 04/18/2011] [Accepted: 04/23/2011] [Indexed: 11/09/2022]
Abstract
Obesity is a growing worldwide epidemic, increasingly addressed through surgical options for weight loss. Benefits of these operations, such as weight loss and improvement or reversal of obesity-related comorbidities, are well established; however, postoperative complications do occur. This article will evaluate common causes for hospital admissions in the post-bariatric surgery population as they relate to the hospitalist who is often responsible for their care. Here we provide an overview of the most common bariatric procedures currently performed, early postoperative complications, late medical complications (ie, abdominal complaints, weight fluctuations, nutritional deficiencies, and metabolic bone disease), and late surgical complications that often affect these patients and result in hospital admissions. Special attention will be paid to radiologic pearls that can assist in the initial evaluation and diagnosis of these patients.
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Gill RS, Whitlock KA, Mohamed R, Birch DW, Karmali S. Endoscopic Treatment Options in Patients With Gastrojejunal Anastomosis Stricture Following Roux-en-Y Gastric Bypass. Gastroenterology Res 2012; 5:1-5. [PMID: 27785171 PMCID: PMC5051034 DOI: 10.4021/gr385w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2012] [Indexed: 12/16/2022] Open
Abstract
The proportion of obese individuals continues to increase worldwide. Bariatric surgery remains the only evidence-based treatment strategy to produce marked weight loss. Roux-en-Y gastric bypass is an effective and common bariatric surgical procedure offered to obese patients. However, a small percentage of individuals can develop narrowing or stricture formation of the gastrojejunal anastomosis. Endoscopic treatment of gastrojejunostomy (GJ) is preferred compared to surgical revision, as it is less invasive. The endoscopic treatment strategy most common employed is balloon dilatation. Endoscopic balloon dilatation is successful in majority of cases with low morbidity, however multiple dilatation may be required. Other endoscopic strategies such as incisional therapy has been successful in treating other gastrointestinal anastomotic strictures, however remain to be evaluated in post-RYGB GJ strictures. Further research is needed to determine the effectiveness of incision therapy and other endoscopic treatment strategies compared to endoscopic balloon dilatation.
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Affiliation(s)
- Richdeep S Gill
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Richdeep S. Gill and Kevin A. Whitlock were co-first authors
| | - Kevin A Whitlock
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Richdeep S. Gill and Kevin A. Whitlock were co-first authors
| | - Rachid Mohamed
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Daniel W Birch
- Center of the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Gill RS, Whitlock KA, Mohamed R, Sarkhosh K, Birch DW, Karmali S. The role of upper gastrointestinal endoscopy in treating postoperative complications in bariatric surgery. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:37-41. [PMID: 22586549 DOI: 10.4161/jig.20133] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/21/2011] [Accepted: 12/23/2011] [Indexed: 12/17/2022]
Abstract
There are an estimated 500 million obese individuals worldwide. Currently, bariatric surgery has been shown to result in clinically significant weight loss. With increasing demand for bariatric surgery, endoscopic techniques used intra and postoperatively continue to evolve. Endoscopic evaluation of anastomotic integrity following RYGB allows for early detection of anastomotic leaks. Furthermore, endoscopy is a valuable tool to diagnose and treat RYGB postoperative surgical complications such as anastomotic leakage, hemorrhage and stricture formation. Early evidence suggests that endoscopic management of upper gastrointestinal hemorrhage following RYGB is effective. In addition, endoscopic balloon dilatation is able to effectively treat obstruction in the setting of gastrojejunal anastomotic strictures. With successful endoscopic management of these complications, bariatric patients may avoid more invasive surgical procedures.
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Affiliation(s)
- Richdeep S Gill
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Hofsø D, Aasheim ET, Søvik TT, Jakobsen GS, Johnson LK, Sandbu R, Aas AT, Kristinsson J, Hjelmesæth J. [Follow-up after bariatric surgery]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:1887-92. [PMID: 21984294 DOI: 10.4045/tidsskr.10.1463] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The number of bariatric surgical procedures in Norway is increasing. Patients who undergo bariatric surgery may experience surgical, medical and nutritional complications. Follow-up of these patients is therefore important. METHODS The article is based on non-systematic literature searches in PubMed and on the clinical experience of the authors. RESULTS Bariatric surgery induces significant and sustained weight loss and improves obesity-related disorders. Gastric bypass is the most commonly performed bariatric procedure in Norway. This procedure is associated with a 30-day mortality of below 0.5 %, while severe complications occur in approximately 5 % of patients. Late complications include internal herniation, intestinal ulcers and gallbladder disease. After surgery all patients are given iron, vitamin D/calcium and vitamin B12 supplements to prevent vitamin and mineral deficiencies. Gastrointestinal symptoms and postprandial hypoglycaemia after surgery can be improved by dietary modifications, and the need for anti-diabetic and blood pressure lowering medications is reduced. Dose adjustment of other medications may also be necessary. Pregnancy is not recommended during the first year after bariatric surgery. Many patients need plastic surgery after the operation. INTERPRETATION Complications after bariatric surgery may manifest in the long term. Regular follow-up is required. General practitioners should be responsible for follow-up in the long term, and should be familiar with common and serious complications as well as normal symptomatology after bariatric surgery.
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Affiliation(s)
- Dag Hofsø
- Senter for sykelig overvekt i Helse Sør-Øst, Sykehuset i Vestfold og Universitetet i Oslo, Norway.
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Morales MJ, Díaz-Fernández MJ, Caixàs A, Cordido F. [Medical issues of surgical treatment of obesity]. Med Clin (Barc) 2011; 138:402-9. [PMID: 21565365 DOI: 10.1016/j.medcli.2011.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 02/25/2011] [Accepted: 03/01/2011] [Indexed: 01/06/2023]
Affiliation(s)
- María José Morales
- Servicio de Endocrinología y Nutrición, Hospital Meixoeiro, Complexo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
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Da Costa M, Mata A, Espinós J, Vila V, Roca JM, Turró J, Ballesta C. Endoscopic dilation of gastrojejunal anastomotic strictures after laparoscopic gastric bypass. Predictors of initial failure. Obes Surg 2011; 21:36-41. [PMID: 20396992 DOI: 10.1007/s11695-010-0154-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most frequent technique performed in bariatric surgery. Gastrojejunal anastomotic stricture is one of the most common postoperative complications. The aims of this study were to evaluate the efficacy and safety of endoscopic balloon dilation in the treatment of the gastrojejunal anastomotic strictures after LRYGB and to look for predicting factors that would indicate the need of repeated dilations. METHODS We included all patients with morbid obesity who underwent a LRYGB at our institution between January 2002 and July 2007. All patients who developed symptoms compatible with stricture of the gastrojejunostomy were referred to upper gastrointestinal endoscopy and underwent endoscopic balloon dilation. RESULTS One hundred and five out of the 1,330 patients (7.8%) developed an anastomotic stricture. The mean time to diagnosis was 3 months after the surgery. The mean diameter of the stricture was 5 mm. Sixty out of the 105 patients required only one dilation (57%), 29 required two dilations (27,6%), 13 required three dilations, and 3 patients underwent a fourth dilation. Clinical success was achieved in 100% of the cases, with an average of 1.6 dilations. The statistical analysis showed that only the time from surgery to stricture formation (p = 0.007) and the diameter achieved at the first dilation (p = 0.015) had statistical significance as predictors of the need of one or more dilations. CONCLUSIONS Endoscopic balloon dilation is a safe and effective method. Most of the patients are successfully managed with one or two dilations. The longer time from surgery to the appearance of symptoms ant the largest diameter achieved at the first dilation are the only predicting factors of success with only one dilation.
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[Endoscopic management of the complications of bariatric surgery. Experience of more than 400 interventions]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:131-6. [PMID: 21377237 DOI: 10.1016/j.gastrohep.2010.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/16/2010] [Accepted: 12/24/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Many patients who undergo bariatric surgery develop postoperative gastrointestinal complications that can require upper gastrointestinal endoscopy. OBJECTIVE To prospectively describe the gastrointestinal complications diagnosed by endoscopy after bariatric surgery. PATIENTS AND METHODS We followed up patients undergoing laparoscopic bariatric surgery between January 1998 and December 2006. The following data were recorded: age, sex, body mass index, comorbidity, type and duration of bariatric surgery, clinical presentation of complications, time of presentation, endoscopic treatment and follow-up. RESULTS A total of 474 patients underwent surgery (74% women, 26% men) with a mean age of 44±11 years (range, 15-66) and a mean BMI of 47±7 (range, 33-82). The most frequent surgical procedure was Roux-en-Y gastric bypass (90%). We identified 68 complications (14%) requiring upper gastrointestinal endoscopy: anastomotic stenosis (21 cases, 5%), upper gastrointestinal hemorrhage (16 cases, 3.6%), epigastric pain (12 cases, 2.5%), vomiting (7 cases, 1.5%), heartburn (6 cases, 1.3%) and other (6 cases, 1.3%). No prognostic factor for the development of complications requiring postsurgical endoscopy was identified. CONCLUSIONS Anastomotic stenosis is the most common complication requiring endoscopic treatment after bariatric surgery. Upper gastrointestinal bleeding in the immediate and late postoperative period can be safely and effectively treated with endoscopic techniques.
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Cusati D, Sarr M, Kendrick M, Que F, Swain JM. Refractory strictures after Roux-en-Y gastric bypass: operative management. Surg Obes Relat Dis 2011; 7:165-9. [DOI: 10.1016/j.soard.2010.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 08/13/2010] [Accepted: 11/05/2010] [Indexed: 10/18/2022]
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Kim JH, Shin JH, Song HY. Benign strictures of the esophagus and gastric outlet: interventional management. Korean J Radiol 2010; 11:497-506. [PMID: 20808692 PMCID: PMC2930157 DOI: 10.3348/kjr.2010.11.5.497] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 02/16/2010] [Indexed: 12/16/2022] Open
Abstract
Benign strictures of the esophagus and gastric outlet are difficult to manage conservatively and they usually require intervention to relieve dysphagia or to treat the stricture-related complications. In this article, authors review the non-surgical options that are used to treat benign strictures of the esophagus and gastric outlet, including balloon dilation, temporary stent placement, intralesional steroid injection and incisional therapy.
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Affiliation(s)
- Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Potack J. Management of post bariatric surgery anastomotic strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2010.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Varghese JC, Roy-Choudhury SH. Radiological imaging of the GI tract after bariatric surgery. Gastrointest Endosc 2009; 70:1176-81. [PMID: 19846080 DOI: 10.1016/j.gie.2009.06.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Accepted: 06/22/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Obesity is becoming epidemic in proportion and is leading to considerable morbidity and mortality in the community. Bariatric surgery offers one tested solution to sustained weight loss and comorbidity reduction. However, it is associated with a significant number of complications. OBJECTIVE The objective of this article is to review the utility of radiological techniques in the diagnosis of surgical complications after bariatric surgery. DESIGN Literature-based review and pictorial illustration in the use of imaging techniques in the diagnosis of complications after bariatric surgery. CONCLUSIONS Radiology plays a critical role in the diagnosis of complications after bariatric surgery. Upper GI contrast study and CT are the most commonly used imaging modalities in this regard. They are complementary in their diagnostic abilities and should be used in concert for the complete evaluation of symptomatic patients. All other radiological imaging modalities are also used in the diagnosis of complications after bariatric surgery, but much less commonly.
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Affiliation(s)
- Jose C Varghese
- Department of Radiology, Quincy Medical Center, Quincy, MA 02169, USA
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Huang CS. The role of the endoscopist in a multidisciplinary obesity center. Gastrointest Endosc 2009; 70:763-7. [PMID: 19555946 DOI: 10.1016/j.gie.2009.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 01/12/2009] [Indexed: 12/16/2022]
Affiliation(s)
- Christopher S Huang
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, 85 E Concord St, no. 7714, Boston, MA 02118, USA
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Rosenthal RJ. Dilating the stenotic gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass for morbid obesity: when things go wrong. J Gastrointest Surg 2009; 13:1561-3. [PMID: 19296180 DOI: 10.1007/s11605-009-0860-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 02/26/2009] [Indexed: 01/31/2023]
Affiliation(s)
- Raul J Rosenthal
- The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA.
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Gastrojejunal Anastomotic Stenosis in Laparoscopic Gastric Bypass with a Circular Stapler (21 mm): Incidence, Treatment and Long-term Follow-up. Obes Surg 2009; 19:1631-35. [DOI: 10.1007/s11695-009-9962-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Accepted: 08/17/2009] [Indexed: 11/30/2022]
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Alasfar F, Sabnis AA, Liu RC, Chand B. Stricture rate after laparoscopic Roux-en-Y Gastric bypass with a 21-mm circular stapler: the Cleveland Clinic experience. Med Princ Pract 2009; 18:364-7. [PMID: 19648758 PMCID: PMC2790757 DOI: 10.1159/000226289] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 10/07/2008] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The objectives of this study were to report the incidence of gastrojejunal anastomic strictures that occurred in laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery and to determine the time course of presentation, associated perioperative factors, and response to balloon dilation. SUBJECTS AND METHODS All 126 patients who underwent LRYGB at the Cleveland Clinic Foundation between July 2003 and February 2005 were included. We utilized a transoral 21-mm circular stapler for the gastrojejunostomy. Patients with symptoms of anastomotic strictures underwent upper endoscopy by one surgeon (B.C.). A stricture was defined by the inability to pass a 10-mm gastroscope through the anastomosis. Balloon dilation was performed to 12 mm. Records were analyzed retrospectively and statistical analysis including Pearson chi(2) statistics, Fisher's exact test and Student's t test were used when appropriate. RESULTS Symptomatic anastomotic strictures occurred in 29 (23%) patients. All patients presented with nausea, vomiting and dysphagia. The median time to diagnosis was 52 days (25-309 days). Symptoms resolved after one dilation in 25 (86%) of patients. Two and three dilations were required in 1 (3.5%) and 3 (10.5%) of patients, respectively. No patients had complications or required more than 3 dilations. Age, preoperative body mass index (BMI), and intraoperative blood loss did not correlate with stricture formation. Although nonsteroidal anti-inflammatory drugs were used by 46 (41%) of patients after surgery, there was no correlation with stricture formation. CONCLUSION Symptomatic anastomotic strictures developed in nearly a quarter of patients who underwent LRYGB utilizing a transoral 21-mm circular stapled gastrojejunal anastomosis. A single endoscopic balloon dilation was usually adequate. Strictures were not predicted by perioperative factors.
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Affiliation(s)
- Fahad Alasfar
- Department of Surgery, Kuwait University, Safat, Kuwait.
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Ryskina KL, Miller KM, Aisenberg J, Herron DM, Kini SU. Routine management of stricture after gastric bypass and predictors of subsequent weight loss. Surg Endosc 2009; 24:554-60. [PMID: 19585070 DOI: 10.1007/s00464-009-0605-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 05/11/2009] [Accepted: 06/16/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Gastrojejunal anastomotic stricture is the most commonly occurring short-term complication after Roux-en-Y gastric bypass. Endoscopic balloon dilation is the first-line treatment for stricture. However, an optimal dilation protocol has not been identified. This study aimed to document routine management of stricture after laparoscopic gastric bypass and its impact on postoperative weight loss. METHODS Charts of patients who underwent gastric bypass from 2000 to 2006 were reviewed using a standardized abstraction form. Patients with stricture were matched with control subjects based on age +/-5 years, gender, and preoperative body mass index (BMI +/- 5). Patients with at least 6 months of follow-up assessment were included in the study. RESULTS Of the 113 patients included in the study, 20% were male, 26% black, 19% Hispanic, and 51% white. Their mean age was 42 +/- 10 years (range, 22-66 years). The mean preoperative BMI was 47.0 +/- 5.4 kg/m(2) for the case group and 46.6 +/- 5.5 kg/m(2) for the control group (p = 0.3). After adjustment for patient characteristics, using a larger balloon was associated with reduced odds of stricture recurrence (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12-0.85; p = 0.02). All the patients were without signs or symptoms of stricture at the last follow-up visit (20 +/- 17 months). Weight loss was similar between the two groups. The percentage of estimated weight loss (%EWL) at 12 months postoperatively was 66% for the study participants and 67% for the control subjects (p = 0.5). Baseline alcohol use and higher preoperative BMI were associated with a higher BMI 6 months postoperatively (p = 0.004 and p < 0.001, respectively). CONCLUSIONS Initial dilation with a larger balloon is safe and may prevent stricture recurrence. Further study of modifiable risk factors for reduced weight loss after surgery, such as alcohol use, may improve patient outcomes.
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Affiliation(s)
- Kira L Ryskina
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
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Lee JK, Van Dam J, Morton JM, Curet M, Banerjee S. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol 2009; 104:575-82; quiz 583. [PMID: 19262516 DOI: 10.1038/ajg.2008.102] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Roux-en-Y gastric bypass (RYGB) is a common intervention for morbid obesity. Upper gastrointestinal (UGI) symptoms are frequent and difficult to interpret following RYGB. The aim of our study was to examine the role of endoscopy in evaluating UGI symptoms after RYGB and to assess the safety and efficacy of endoscopic therapy. METHODS Between 1998 and 2005, a total of 1,079 patients underwent RYGB for clinically severe obesity and were followed prospectively. Patients with UGI symptoms after RYGB who were referred for endoscopy were studied. RESULTS Of 1,079 patients, 76 (7%) who underwent RYGB were referred for endoscopy to evaluate UGI symptoms. Endoscopic findings included normal surgical anatomy (n=24, 31.6%), anastomotic stricture (n=40, 52.6%), marginal ulcer (n=12, 15.8%), unraveled nonabsorbable sutures causing functional obstruction (n=3, 4%) and gastrogastric fistula (n=2, 2.6%). Patients with abnormal findings on endoscopy presented with UGI symptoms at a mean of 110.7 days from their RYGB, which was significantly shorter than the time of 347.5 days for patients with normal endoscopy (P<0.001). A total of 40 patients with anastomotic strictures underwent 86 endoscopic balloon dilations before complete symptomatic relief. In one patient, a needle knife was used to open a completely obstructed anastomotic stricture. Unraveled, nonabsorbable suture material was successfully removed using endoscopic scissors in three patients. CONCLUSIONS Patients presenting with UGI symptoms less than 3 months after surgery are more likely to have an abnormal finding on endoscopy. Endoscopic balloon dilation is safe and effective in managing anastomotic strictures. Endoscopic scissors are safe and effective in removing unraveled, nonabsorbable sutures contributing to obstruction.
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Affiliation(s)
- Jeffrey K Lee
- Department of Medicine, University of California, San Diego, USA
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Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg 2009; 19:495-9. [PMID: 19169764 DOI: 10.1007/s11695-009-9803-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Accepted: 01/08/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sleeve gastrectomy (SG) can be performed either as isolated (ISG), or with the malabsorptive procedure of duodenal switch (SG/DS). Among the postoperative complications, stenosis of the SG is relatively rare and only scarcely mentioned in literature. We report our experience in nine patients presenting a long stenosis, not eligible for endoscopic balloon dilation, and treated by laparoscopic seromyotomy after ISG or SG/DS. METHODS From March 2006 to January 2008, four patients after ISG (0.7%) and five patients after SG/DS (0.8%) were consecutively submitted to laparoscopic seromyotomy for long stenosis, not eligible for endoscopic balloon dilation. Dysphagia appeared after a mean time of 9.2 +/- 2.6 months (ISG) and of 18.6 +/- 13.2 months (SG/DS). Preoperative mean dysphagia frequency was 4 +/- 0 (ISG) and 4 +/- 0 (SG/DS). Gastroesophageal reflux disease (GERD) symptoms appeared as de novo in two patients of both groups. Barium swallow showed a stenosis at the upper part of the SG (2) and at the level of the incisura angularis (7). Gastroscopy evidenced a mean length of the stricture of 4.7 +/- 0.9 cm (ISG) and of 5.2 +/- 1.3 cm (SG/DS). The primary outcomes measure was stricture healing rate. Secondary outcomes measures included procedure time, peroperative, and postoperative complications, performance of barium swallow check, and GERD symptoms improvement. RESULTS There were no conversions to open surgery and no mortality. There was no peroperative gastric perforation, but one patient was converted into Roux-en-Y gastric bypass (ISG). Mean operative time was 153.7 +/- 39.4 min (ISG) and 110 +/- 6.1 min (SG/DS). One gastric leak was recorded postoperatively (ISG). Mean hospital stay was 7.6 +/- 5.8 days (ISG) and 3.4 +/- 0.8 days (SG/DS). Barium swallow check after 1 month was satisfied in all patients, and they were able to tolerate a regular diet. After a mean follow-up of 21 +/- 5.6 months (ISG), the mean dysphagia score was reduced to 0.6 +/- 0.9, and after a mean follow-up of 17.6 +/- 10.5 months (SG/DS) to 0.8 +/- 0.8. De novo GERD symptoms improved in two patients of both groups. CONCLUSION Laparoscopic seromyotomy after SG for long stenosis is feasible, and efficient for the treatment of symptomatic dysphagia. It has a beneficiary influence on de novo GERD symptoms improvement. There is, however, the risk of postoperative leak.
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Kim JH, Shin JH, Song HY. Fluoroscopically guided balloon dilation for benign anastomotic stricture in the upper gastrointestinal tract. Korean J Radiol 2009; 9:364-70. [PMID: 18682675 PMCID: PMC2627276 DOI: 10.3348/kjr.2008.9.4.364] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A benign anastomotic stricture is a common complication of upper gastrointestinal (UGI) surgery and is difficult to manage conservatively. Fluoroscopically guided balloon dilation has a number of advantages and is a safe and effective procedure for the treatment of various benign anastomotic strictures in the UGI tract.
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Affiliation(s)
- Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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